ICD 10 is here!!! Getting Ready for ICD-10: Cracking the Code. CPT vs ICD. Definitions. WHY do we have to use these codes?
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1 Getting Ready for ICD-10: Cracking the Code Marshall Grodofsky, MD, FAAAAI Priya J. Bansal, MD FAAAAI Workshop 2011 March 1, 2014 San Diego, CA ICD 10 is here!!! Will be used for Outpatient services October 1, (NOT BEFORE.) 6 fold increase of available Diagnosis codes will allow for more complex and specific detail in diagnosis. THIS DOES NOT increase complexity of the procedure during the visits (Diagnosis codes is different from Procedure codes) Definitions International Classification of Diseases (10 th edition), Clinical Modification or ICD-10-CM versus Coding Procedural Terminology or CPT CPT Procedure Codes How we paid (for Procedures we do) Based on Complexity RVU linked Physician care about this Is the patient covered?" CPT vs ICD ICD Diagnosis Codes Describes patient Unrelated to physician reimbursement But labels patient so pts care (future life insurability, pre-existing conditions ) Diagnosis code should support procedures performed. Difference between Procedure (CPT) Codes & Diagnosis (ICD) Codes Insurances pay us for our Procedures (CPT Codes). NOT DIAGNOSES!!! They still might not recognize all CPT Codes. However, Diagnosis Codes support the reasons for the Procedures. Payers will all have to collect all ICD codes! WHY do we have to use these codes? It s the Law!!! IT will NOT help improve patient care. No physician or Insurer wanted this change The CDC people (& other epidemiologists) want to use physicians as data collectors, so THEY can gain information and get more specific patient info! (SORRY!!!) 1
2 HISTORY 0f ICD-10 ICD-10 (invented here in USA) was endorsed by the 43 rd World Health Assembly in May of Came into use in ICD-11 is just around the corner! Reality is that this is just a language issue. As physicians we really know & use these terms and categories! Delays to date Electronic Data submissions standards had to be updated to handle the increased data (5010 standard). Was finally met January 1, format accommodates 12 diagnosis codes per claim No more delay despite complaints on multiple fronts (mostly PAYERS!) Advantages of ICD-10 More specific & descriptive will allow us to state why many of our patients come to see us. (Rule out allergies because of Family history, or vague past medical history that is uncertain). ICD-10 Z codes Reduces the need for attachments to explain the patient s condition Claims should be processed quicker Advantages of ICD-10 Now we can easily distinguish between CPT codes (always 5 numbers) versus Diagnosis codes (which now always start with a Letter). No way that a 1 page superbill with all diagnosis codes can exist! You will have to have sets of diagnosis codes linked together in your systems, which could be brought up easily for each patient. Definitely will force us to be more specific (when we can). Seems that we will be forced to stay away from Non-specific (exact etiologies will be detailed). Clearly there is going to be semantics and language problems (ie. There are 2 different ICD-10 codes for Shortness of Breath & Dyspnea) 2
3 Confusion in reading the ICD-10 Code book: inclusion terms will list some of the terms to be used, but in a confusing syntax (ie. Code for history of peanut allergy is Z91.010, but the written text states allergy status, other than to drugs & biological substances, allergy to peanut????) USE of NEC = other specified, & NOS= Unspecified Use of and means and/or - excludes notes Excludes 1 indicates that code should NEVER be used at the same time as the listed exceptions in the excludes 1 note. (ie. Anaphylactic rx to peanuts, T78.01-, not used with anaphylaxis to nuts & seeds, T78.05Xx ). Excludes 2 indicates that the condition excluded IS NOT part of the condition represented by the code, but the patient may also use the second listed code at the same visit.(ie. Wheezing, R06.2 with asthma codes,j45.-- ) BOTH Chronic & Acute conditions (ie. Sinusitis) can be used in the same patient encounter. (acute code goes 1 st ) Codes will change from one day to the next (ie. Contact Dermatitis codes might change from day of first visit, before patch test results, to 4 th day after Patch tests are read. Also specified L23.-- versus unspecified L th digit = a for initial visit or reaction, versus d for subsequent visit, & s for sequela With/Without : When with and without are the two options for the final character of a set of codes, the default is always WITHOUT ie. Extrinisic or IntrinsicAsthma with Status asthmaticus is J45.902, as opposed to other asthma codes J45.901, J45.909, or J45.998; Same is seen with the mild, moderate, or severe persistent asthma codes Potential Benefit to Us: Example: Use of Spirometry in our patients with Allergic Rhinitis but no documented asthma. Technically no reason to do spirometry if we only diagnose only Rhinitis Codes (J30.XX- J31.0), but if you also code breathing/coughing problems (ie. Dyspnea/Shortness of Breath Codes- R06.XX, or Coughing- R05, or Chest Pain Codes R07.8X ) we should be all right ICD-9 CM Versus ICD-10CM ICD-9-CM 3-5 characters First character is numeric or alpha (E or V) Characters 2-5 are Numeric Always at least 3characters Use of decimal after 3 characters ICD-10-CM 3-7 characters Character 1 is alpha (all letters except U are used) Character 2 is numeric Characters 3-7 are alpha or numeric Use of decimal after 3 characters Use of dummy placeholder x Alpha characters are not casesensitive 3
4 ICD-10 CM Character Layout 1st Character name of section 2nd Character body system 3rd Character etiology 4th Character anatomical site 5th Character severity 6th Character device 7th Character- qualifier (extension) only used in some sections of the system ICD-10 CM Coding Guidelines Code to the highest degree of specificity documented Statistic 65% of all providers documentation lacks the degree of specificity required for ICD-10CM ONGOING ISSUE Document, Document, Document!!!! If it s not recorded, it did not happen! If it is illegible it did not happen! ICD-10CM Coding Guidelines Locate the term in the alphabetic index Verify the code in the tabular list Read instructional notations that appear in both alphabetic Index and tabular index A dash (-) at the end of an alphabetic index indicates that additional characters are required ICD 10 Downloadable book Joint Council of AAI has made cheat sheet available ftp://ftp.cdc.gov/pub/health_statistics/nchs/ Publications/ICD10CM/ D9_to_ICD10_final.pdf 4
5 Conversion sites between ICD-9 & ICD Z Codes will be very helpful Encounter for allergy testing (Z01.82) Personal history codes for peanut allergy (Z91.010) ; variety of specific foods (Z Z91.02); & other things (again definitive separate codes in Z91.0XX ) Drug Allergy codes: to Penicillin (Z88.0); or other drugs (Z88.1-Z88.9) Asthma Codes could now change with each visit Asthma codes (J45.20-J45.998) is mostly based on Asthma severity score (but also with codes that note acute exacerbation, or status asthmaticus Cough variant asthma with separate code (J45.991) Exercise induced asthma (J45.990) Anaphylaxis Will require specific coding. Patient with Personal history of anaphylaxis gets Z code PLUS the historical agent reported (Z88.- codes or Z91.0- codes for non-foods) Hx of anaphylaxis to a food use T78.00Xx (where the 7 th digit would be a for initial visit; d for subsequent visit; or s for a sequela from the anaphylaxis). Shot reactions If pt has system reaction to shot first code to use would be T88.6XXa to designate an acute anaphylactic rx given at that initial visit for properly administered drug or medication. Plus you would record the code of why you were giving shots for (pollen allergens, or insect venom hypersensitivity, etc). Respiratory Symptoms & signs Confusion in my mind about when to use the codes for shortness of breath, versus dyspnea Marshall Grodofsky s opinion: Use shortness of breath code (R06.02) for patient history of SOB. Orthopnea R06.01 also would be history of SOB with laying down. Dyspnea (R06.00) is a finding by physician on physical exam. 5
6 Confusion over different Contact Derm Codes Two sets of codes from L23.0- L25.9 L23.- codes allergic contact dermatitis L25.- codes are unspecified contact derm What s the difference?????? Marshall Grodofsky s guess is that the L23.- codes are patch test proven, and the L25.- codes are historically suggested. Any other guesses????? Getting Ready Learn the most common allergy codes: ie. Asthma codes, Allergic Rhinitis codes, anaphylaxis codes, Food & Drug Allergy codes. Start being more specific in how you document NOW! (ie. Classify every visit in pts with asthma by their severity at time of visit. Also document positive specific allergens for the AR at every visit!) Getting Ready Review your own favorite ICD-9 codes and start making up your own cheat sheet with expanded listing ICD-10 codes. I suggest personally editing the descriptive terms that can be entered into your Electronic Health record systems making it easier for you to find the codes you want to use when October 1 comes. Make sure your systems are ICD-10 compatible NOW. Do the Best You can Remember it is NOT FRAUDULANT to semantically use different terms. (We charge & get paid by CPT Codes- Don t EVER CHARGE for service you didn t perform) If you think the patient has a diagnosis that you think you adequately documented then I think you should be OK!!!! Patient Scenarios Good Luck! 6
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