coding: icd 10 and common coding questions
TRANSCRIPT
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Coding:ICD‐10 and Common Coding Questions
Mark N. Painter
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Objectives
• Successfully adapt current coding and documenation practices to the New ICD‐10‐ CM system
• Properly bill “incident to” encounters
• Determine coding for the appropriate level of MDM for evaluation and management services
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ICD‐10 Preparation
• Designate a champion in the practice
• Check with vendor preparations
• Begin template redesign
• Think detail
• Reason, duration, cause, associated Dx, sequencing
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ICD‐9‐CM vs ICD‐10‐CM OverviewICD‐9‐CM Diagnosis Codes ICD‐10‐CM Diagnosis Codes
Approximately 14,000 codes Approximately 69,000 codes
3‐5 characters in length 4 – 7 characters in length
First digit may be alpha (E or V) or numeric. Digits 2 – 5 are numeric
Digit 1 is alpha; digit 2 and 3 are numeric; digit 4 – 7 are alpha
Limited space for new codes Flexible for adding new codes
Lacks detail Very specific
Lacks laterality Has laterality
No placeholder Characters Has a placeholder character –character “X” used as 5th and 6th
character placeholder to allow for expansion
Procedure (PCS) Codes:ICD-9 - 3,824 codes ICD-10 - 72,589 codes
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Considerations
• Your EMR is going to have to change
– Will there be changes to your templates
– Can you run both systems now?
– Will you need to learn new search features
– Develop a backup system for the first few weeks of ICD‐10, there will be glitches.
– Get training if you need it (book training now, cancel later if you do not need it)
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ICD‐ 10 Format and Structure
Overall similar to ICD‐9‐CM• Alphabetic Index
– Index of disease and injury– Index of External Causes of Injury– Table of Neoplasms– Table of Drugs and ChemicalsOrganized by main term describing the disease and/or condition
• Tabular list – Body System– ConditionOrganized by chapters based on body system or condition – similar
but differences
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ICD‐10‐CM TABULAR LIST of DISEASES and INJURIES ‐ Table of Contents
1 Certain infectious and parasitic diseases (A00‐B99)
2 Neoplasms (C00‐D49)
3Diseases of the blood and blood‐forming organs and certain disorders involving the immune mechanism (D50‐D89)
4 Endocrine, nutritional and metabolic diseases (E00‐E89)
5 Mental and behavioral disorders (F01‐F99)
6 Diseases of the nervous system (G00‐G99)
7 Diseases of the eye and adnexa (H00‐H59)
8 Diseases of the ear and mastoid process (H60‐H95)
9 Diseases of the circulatory system (I00‐I99)
10 Diseases of the respiratory system (J00‐J99)
11 Diseases of the digestive system (K00‐K94)
12 Diseases of the skin and subcutaneous tissue (L00‐L99)
13 Diseases of the musculoskeletal system and connective tissue (M00‐M99)
14 Diseases of the genitourinary system (N00‐N99)
15 Pregnancy, childbirth and the puerperium (O00‐O99)
16 Certain conditions originating in the perinatal period (P00‐P96)
17 Congenital malformations, deformations and chromosomal abnormalities (Q00‐Q99)
18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00‐R99)
19 Injury, poisoning and certain other consequences of external causes (S00‐T88)
20 External causes of morbidity (V00‐Y99)
21 Factors influencing health status and contact with health services (Z00‐Z99)
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XX
Category Etiology, anatomic site, severity
Added code extensions (7th
character) for obstetrics,
injuries, and external causes of
injury
ICD‐10‐CM Structure
X XN 4 0 3.
Additional Characters
Alpha (Except U)
2 Always Numeric3-7 Numeric or Alpha
3 – 7 Characters
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• Urolithiasis (N20‐N23)
• N20 Calculus of kidney and ureter – Calculous pyelonephritisExcludes1: nephrocalcinosis (E83.5)
that with hydronephrosis (N13.2)
• N20.0 Calculus of kidney – Nephrolithiasis NOS Renal calculus Renal stone Staghorn calculus Stone in kidney
• N20.1 Calculus of ureter – Ureteric stone
• N20.2 Calculus of kidney with calculus of ureter • N20.9 Urinary calculus, unspecified
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Top Dx Cross Walk
2014 GEM
591Hydronephrosis N13.1
Hydronephrosis with ureteral stricture, not elsewhere classified
N13.2Hydronephrosis with renal and ureteral calculous obstruction
N13.30 Unspecified hydronephrosis
N13.39 Other hydronephrosis
236.91 Renal Mass N28.89 Other Specified Disorders of the Kidney and Ureter
592.0 Calculus of Kidney N20.0 Calculus of kidney
N20.2 Calculus of kidney with calculus of ureter
592.1 Calculus of Ureter N20.1 Calculus of Ureter
189.0 Renal Cancer C64.1 Malignant neoplasm of right kidney, except renal pelvis
C64.2 Malignant neoplasm of left kidney, except renal pelvis
C64.9Malignant neoplasm of unspecified kidney, except renal pelvis
593.2 Renal Cyst N28.1 Cyst of kidney, acquired
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2014 GEM
185 Prostate Cancer C61 Malignant neoplasm of prostate
600.01 BPH w/ obstruction N40.1 Enlarged prostate with lower urinary tract symptoms
600.00 BPH w/o obstruction N40.0 Enlarged prostate without lower urinary tract symptoms
601.0 Prostatitis, Acute N41.0 Acute prostatitis
601.1 Prostatitis, Chronic N41.1 Chronic prostatitis
602.3 Dysplasia of prostate N42.3 Dysplasia of prostate
790.93 Elevated PSA R97.2 Elevated prostate specific antigen [PSA]
ICD-9 GEM Crosswalk
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2014 GEM
188.9 Bladder CancerC67‐
Bladder Cancer ☐(.0)Trigone ☐(.1) dome ☐(.2) lateral wall ☐(.3) anterior wall ☐(.4) posterior wall ☐(.5) bladder neck ☐(.6) ureteric orifice ☐(.7) urachus ☐(.8) overlapping sites ☐(.9) unspecified
595.0 Acute cystitis N30.00 Acute cystitis without hematuria
N30.01 Acute cystitis with hematuria
595.1 Interstitial Cystitis N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
595.2 Other chronic cystitis N30.20 Other chronic cystitis without hematuria
N30.21 Other chronic cystitis with hematuria
596.51 OAB N32.81 Overactive bladder
596.54 Neurogenic Bladder N31.0 Uninhibited neuropathic bladder, not elsewhere classified
N31.1 Reflex neuropathic bladder, not elsewhere classified
N31.9 Neuromuscular dysfunction of bladder, unspecified
GEM Crosswalk
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2014 GEM
257.2 Hypogonadism E29.1 Testicular hypofunction
598.1 Traumatic urethral stricture N35.010 Post‐traumatic urethral stricture, male, meatal
N35.011 Post‐traumatic bulbous urethral stricture
N35.012 Post‐traumatic membranous urethral stricture
N35.013 Post‐traumatic anterior urethral stricture
N35.014 Post‐traumatic urethral stricture, male, unspecified
N35.021 Urethral stricture due to childbirth
N35.028 Other post‐traumatic urethral stricture, female
598.9 Urethral stricture, unspecified N35.9 Urethral stricture, unspecified
599.0 Urinary tract infection, site not specified N39.0 Urinary tract infection, site not specified
599.71 Gross hematuria R31.0 Gross hematuria
599.72 Microscopic hematuria R31.1 Benign essential microscopic hematuria
R31.2 Other microscopic hematuria
603.0 Encysted hydrocele N43.0 Encysted hydrocele
604.9 Orchitis and epididymitis, unspecified N45.1 Epididymitis
N45.2 Orchitis
N45.3 Epididymo‐orchitis
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2014 GEM
605 Redundant prepuce and phimosis N47.0 Adherent prepuce, newborn
N47.1 Phimosis
N47.2 Paraphimosis
N47.3 Deficient foreskin
N47.4 Benign cyst of prepuce
N47.5 Adhesions of prepuce and glans penis
N47.7 Other inflammatory diseases of prepuce
N47.8 Other disorders of prepuce
607.84 Impotence of organic origin N52.01 Erectile dysfunction due to arterial insufficiency
N52.02 Corporo‐venous occlusive erectile dysfunction
N52.03Combined arterial insufficiency and corporo‐venous occlusive erectile dysfunction
N52.1 Erectile dysfunction due to diseases classified elsewhere
N52.2 Drug‐induced erectile dysfunction
N52.31 Erectile dysfunction following radical prostatectomy
N52.32 Erectile dysfunction following radical cystectomy
N52.33 Erectile dysfunction following urethral surgery
N52.34 Erectile dysfunction following simple prostatectomy
N52.39 Other post‐surgical erectile dysfunction
N52.8 Other male erectile dysfunction
N52.9 Male erectile dysfunction, unspecified
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2014 GEM
608.1 Spermatocele N43.40 Spermatocele of epididymis, unspecified
N43.41 Spermatocele of epididymis, single
N43.42 Spermatocele of epididymis, multiple
608.9
Unspecified disorder of male genital organs N50.9 Disorder of male genital organs, unspecified
R10.2 Pelvic and perineal pain
625.6
Stress incontinence, female N39.3 Stress incontinence (female) (male)
724.2 Lumbago M54.5 Low back pain
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2014 GEM
788.1 Dysuria R30.0 Dysuria
R30.9 Painful micturition, unspecified
788.21Incomplete bladder emptying R39.14 Feeling of incomplete bladder emptying
788.31 Urge incontinence N39.41 Urge incontinence
788.33
Mixed incontinence (male) (female) N39.46 Mixed incontinence
788.41 Urinary frequency R35.0 Frequency of micturition
788.43 Nocturia R35.1 Nocturia
788.63Urgency of urination R39.15 Urgency of urination
789Abdominal pain, unspecified site R10.0 Acute abdomen
R10.9 Unspecified abdominal pain
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Incident to Billing
• Medicare definitions:
• “Incident to” services are defined as services commonly furnished in a physician’s office which are “incident to” the professional services of a physician (MD or DO) and are limited to situations in which there is direct physician personal supervision.
• Direct supervision for the physician office does not require to physician to be present in the room when the patient is seen nor does it require physician patient contact. However, the physician reporting the service (billing provider) must be in the facility and immediately available when services are provided.
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Incident to Billing ‐ Office
• The plan of care for the patient must be established during a visit in which the physician has direct patient contact and clearly documents a plan of care for the problem. This does not mean that on each occasion of an incidental service performed by an NPP, that the patient must also see the physician. It does mean there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the services being performed by the NPP is an incidental part.
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Incident to Billing‐office
• TRANSLATION:
• NPP cannot see new patients or established patients with a new problem and bill“incident to”
• Some carriers have interpreted this guideline to mean that any change in treatment plan not initiated during a visit in which the physician is an integral part of the service (direct contact required) that visit any subsequent visit for the care are no longer eligible for “incident to” billing.
• NOT ALL MEDICARE MACs AGREE completely. ALL agree that any significant change in treatment or encounter for a new problem do not qualify for “incident to” service billing.
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Incident to Billing not allowed in the Hospital
• Services and supplies that would normally be covered “incident to” in an office setting, such as NPs that the physician hires and supervises, are not billable by the physician in hospital settings.
• If the physician uses the services of his/her own employees in a hospital setting and the physician merely supervises his/her services, the Service must be reported under the NPP NPI.
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Incident to Billing
• OTHER PAYERS
• May reimburse for non‐physician providers' services differently
• Many state laws allow a general delegation of authority with responsibility retained by the physician without requiring on‐premises supervision.
• Check contract and payer websites
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E&M coding“Take back”‐ risk
• Medical Necessity
• “Cloning” of records
• Documentation
• Not signing encounters
• Misuse of modifiers
• Charges outside the norm
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Documentation
• Proof of Service
• Medical Necessity
• Separate and Unique documentation for each service to be charged
• Forms / Templates
• Develop / Update
• Hx and PE
17
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E&M Documentation ‐Cloning
–Office of Inspector General's ( OlG) Work Plan
– "Medicare contractors have noted an increased frequency of medical records with identical documentation across services,”
– "We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records [EHR] documentation practices associated with potentially improper payments.”
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26
E&M Coding tips‐ Time and/or Components
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27
AU
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01
0
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Potential level 5– New Pt• Requires a complete Hx and PE
documented the following is a guide for each level.
• MDM• Patient w/acute sepsis in need of diagnostic tests to decide
treatment.
• Patient w/multiple lab tests, CT scan or x-ray requiring major surgery with identified risk factors
• Patient w/multiple active problems (stone and BPH and ED) requiring major surgery with identified risk factors
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Potential level 4– New Pt• Requires a complete Hx and PE
documented the following is a guide for each level.
• MDM• New problem to you with Rx drug ordered
• New problem with multiple lab and X-Ray test or a diagnostic endoscopy.
• New problem requiring lithotripsy either through scope or ESWL
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Potential level 3– New Pt
• You must have a 3rd level Hx and Detailed PE
• MDM
• New problem with 2 data points or an acute uncomplicated illness
• New problem with minor surgery no risk factors
• New problem with patient treated with over-the-counter drugs or physical therapy
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Modifier ‐25 and 57
• 25‐ Significant, separately identifiable‐ E/M service by the same physician onday of the procedure.”
• 57‐ Decision for Surgery:‐ Append to an E/M service that resultedin the initial decision to perform thesurgery.
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E&M modifiers‐ Private Payer
• Not Required to follow Medicare and CPT Rules or Guidelines
• May Recognize Modifier ‐57 over with 0 and 10 Global
• Procedures‐May Require a separate diagnosis
• May use greater Global Periods
• May continue to pay for consultations
• Payers Involved in Class Action are required to Recognize CPT modifiers
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I saw a patient on his initial visit for ED and initiated a plan. He saw the MD at the next visit and the MD stayed the course and did not change my plan. Since the MD now has seen the patient, may I bill “incident to” for subsequent visits?
Yes
No
Scenario 1
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I am seeing an established patient for follow up and now he has a new complaint. Can I still bill “incident to?”
Yes
No
Scenario 2
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I have a new patient with hematuria. Can I do a cystoscopy on her the same day and bill for both the new patient visit and the cystoscopy?
Yes
No
Scenario 3
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I saw a new patient for incontinence. She is 82yo and has medicare. I did a UA, bladder scan and did a full Hx and PE including a pelvic exam. Her diagnosis was stress incontinence and atrophic vaginitis. I placed her on oxybutynin 5mg po qd and on estrogen cream and am having her f/u in 6 weeks to see the doctor for a reassessment. What is the correct code for the visit?
99203 99204 99205
Scenario 4
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Questions