ED Coding and Reimbursement Alert

Check out these ED-relevant unspecified codes to prevent future denials.

October 1, 2016 marks the end of the one year grace period for post payment reviews related to ICD-10 specificity. That means your ICD-10 coding needs to be accurate enough to stand up to CMS scrutiny.

Problem: Widespread use of unspecified codes could cause claim rejections and post payment reviews.  Exactly what will the Centers for Medicare & Medicaid Services (CMS) and other commercial payers will deny is still unknown. But coding with specificity and not relying on unspecified codes could help safeguard your claims.

Although specificity is the name of the game when reporting ICD-10 codes post-grace period, all of the codes listed below are appropriate to use when further more specific documentation details are not provided, says Stacie Norris, MBA, CPC, CCS-P, Director of Coding Quality Assurance for Zotec Partners in Durham NC

*Multiple ICD-10 codes for open wound of finger, depending upon laterality, which finger, with or without damage to the nail, for example S60.019 (Contusion of unspecified thumb, without damage to the nail)

Consider these documentation hints for common ED presentations from Norris:

Chest Pain

Chest pain includes more specific locality and type.

Options:

• R07.1 (Chest pain on breathing)
• R07.2 (Precordial pain)
• R07.81 (Pleurodynia)
• R07.82 (Intercostal pain)
• R07.89 (Other chest pain [anterior chest-wall pain NOS])

Abdominal Pain

Abdominal pain includes more specific location, quadrant, and type.

Options:

• R10.0 (Acute abdomen)
• R10.10 (Upper abdominal pain, unspecified)
• R10.11 (Right upper quadrant pain)
• R10.12 (Left upper quadrant pain)
• R10.13 (Epigastric pain)
• R10.2 (Pelvic and perineal pain)
• R10.30 (Lower abdominal pain)
• R10.31 (Right lower quadrant pain)
• R10.32 (Left lower quadrant pain)
• R10.33 (Periumbilical pain)
• R10.84 (Generalized abdominal pain)

Quick Facts About The ICD-10 Grace Period 

• This one-year grace period offered by the Centers for Medicare & Medicaid Services (CMS) runs from October 1, 2015 – September 30, 2016
  
• During the grace period, Medicare review contractors won’t deny claims through automated medical review based solely on the specificity of the ICD-10 diagnosis code as long as a valid code was used from the correct family.
  
• The grace period was adopted by Medicare Administrative Contractors (MAC), the Recovery Audit Contractors (RAC), the Zone Program Integrity Contractors (ZPIC), and the Supplemental Medical Review Contractor (SMRC).
• Intended for auditing purposes, the grace period allows less than the most specific codes within a family to be accepted. The requirement for accurate and specific coding did not change, only the leniency that would be shown during the auditing process.
  

Note: Code left or right flank/side pain with an unspecified pain code because ICD-10 only defines the quadrants and upper or lower pain. 

Fever

Fever includes the cause of the fever.

Examples:

• R50.2 (Drug induced fever)
• R50.82 (Postprocedural fever)
• R50.83 (Postvaccination fever)

Pneumonia

Pneumonia includes the specific type. 

Examples:

• J12.9 (Viral pneumonia) 
• J19.0 (Bronchial pneumonia)
• J15.9 (Bacterial pneumonia)
• J15.5 (E. Coli pneumonia)
• J18.1 (Lobar pneumonia)

Dorsalgia

Use a specified ICD-10 code for a diagnosis of back pain if the specific location and cause (if known) of the back pain is documented. 

Examples:

• M54.16 (Radiculopathy, lumbar region)
• M54.31 (Sciatica, right side)
• M54.5 (Low back pain)
• M54.6 (Pain in thoracic spine)

Neck Sprain and Ankle Sprain

Three important key elements when documenting all injuries:

Location:

It is always important to document the specific location of any patient injury.  For joint injuries, document the specific joint or ligament involved when known.  Providing this information in the documentation will allow the coder to report the case using the highest level of specificity. 

Laterality:

ICD-10 allows for the coding of laterality including right, left, and bilateral.

Type of Injury:

ICD-10 categorizes injuries by the specific type of injury the patient has sustained. Documentation of this detailed information allows the coder to select codes with the highest level of specificity.  Even if the location of the injury is given, but the type of injury isn’t specified, ICD-10 sees this as unspecified documentation.

Sprains are a particular challenge for the ED provider to document because coding a specified code requires knowing the specific ligament(s) that were injured. For neck sprains, here are the choices in ICD-10:

• S13.4XXA (Sprain of ligaments of cervical spine, initial encounter), this includes: sprain of anterior longitudinal ligament, cervical; sprain of atlanto-axial (joints); sprain of atlanto-occipital (joints); and whiplash injury of cervical spine.
• S13.5XXA (Sprain of thyroid region, initial encounter), this includes:  sprain of cricoarytenoid (joint) (ligament); sprain of cricothyroid (joint) (ligament); sprain of thyroid cartilage.
• S13.8XXA (Sprain of joints and ligaments of other parts of neck, initial encounter): this code is to be used when the provider documents a specific joint or ligament sprain that is not covered under S13.4XXA or S13.5XXA.
• S13.9XXA (Sprain of joints and ligaments of unspecified parts of neck, initial encounter)

For ankle sprains, there are numerous options in ICD-10, here a few:

S93.411A (Sprain of calcaneofibular ligament of right ankle, initial encounter)

S93.421A (Sprain of deltoid ligament of right ankle, initial encounter)

Respiratory Infection

Coding for respiratory infections in ICD-10 requires significant detail. This diagnostic specificity (such as the infectious organism) is often unavailable in the ED place of service. Document as much specific detail as possible, including upper or lower, acute or chronic, and exact type if known.

Examples of specific codes:

• J39.8 (Other specified diseases of upper respiratory tract)
• J00 (Acute nasopharyngitis)

Bronchitis

The ICD-10 code set also requires significant detail for bronchitis codes. As with respiratory infection coding, this diagnostic specificity (such as the infectious organism) is often unavailable in the ED place of service. Document as much specific detail as possible, such as acute or chronic and cause if known.

Examples of specific codes:

• J20.2 (Acute bronchitis due to streptococcus)
• J68.0 (Bronchitis and pneumonitis due to chemicals, gases, fumes, and vapors)
• J20.8 (Acute bronchitis due to other specified organism)          

Heart Failure

Heart failure includes the type (acute or chronic) and systolic or diastolic. 

Examples:

• I50.1 (Left ventricular failure)
• I50.21 (Acute systolic [congestive] heart failure)
• I50.22 (Chronic systolic (congestive) heart failure)
• I50.31 (Acute diastolic (congestive) heart failure)

Gastroenteritis

Document as much detail as is known about the gastroenteritis. For example, document the cause if known, such as due to radiation, food-poisoning, drug-induced or allergic. Document the causative organism if known and whether the condition is infectious or non-infectious.

Examples:

• K52.0 (Gastroenteritis and colitis due to radiation)
• K52.2 (Allergic and dietetic gastroenteritis and colitis)
• K52.1 (Toxic gastroenteritis and colitis)
• A02.0 (Salmonella enteritis)

Pharyngitis

The ICD-10 also looks for significant detail for pharyngitis coding. Once again, this diagnostic specificity (such as the infectious organism) is often unavailable in the ED place of service. Document as much specific detail as possible, such as acute or chronic, exact type and cause if known. Also, as with several respiratory system disorders, there are specific combination codes available for “with influenza.”

Examples of specific codes:

• A56.2 (Chlamydial infection of genitourinary tract, unspecified)
• J31.2 (Chronic pharyngitis)
• J02.8 (Acute pharyngitis due to other specified organisms)

Head Injury

There are over 100 head injury codes in the ICD-10 code set. Documentation should state whether the patient has a concussion if, with or without loss of consciousness (LOC) and the length of time of the LOC. It is helpful to document the Glasgow Coma Scale (GCS), a scoring system used to describe the level of consciousness in a person following a traumatic brain injury, to assist in code selection. If there is a skull fracture, document the exact location and with or without LOC, length of LOC. You must document the exact type of injury (for all injuries, not just head injuries). Is it a contusion, abrasion, or open wound? If only “head injury” is documented and there is no other detail on the chart, then the coder will pick the appropriate code from the unspecified intracranial injury section, as ICD-10 directs.

Examples:

• S06.9X0A (Unspecified intracranial injury, without loss of consciousness, initial encounter)
• S06.9X1A (Unspecified intracranial injury, with loss of consciousness of 30 minutes or less, initial encounter)     
• S06.6X1A (Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial encounter)
• S00.83XA (Contusion of other part of head, initial encounter)

Laceration of Finger

Always specify with or without a foreign body involvement when documenting lacerations. For finger lacerations specifically, document with or without damage to the nail (default is without).

Examples:

• S61.220A (Laceration with foreign body of right index finger without damage to nail, initial encounter)
• S61.310A (Laceration without foreign body of right index finger with damage to nail, initial encounter)

Dyspnea

Dyspnea includes the specific type.

Examples:

• R06.01 (Orthopnea)
• R06.02 (Shortness of breath)
• R06.2 (Wheezing)
• R06.4 (Hyperventilation)

Atrial Fibrillation

Document the specific type of atrial fibrillation.

Examples of specific codes available:

• I48.0 (Paroxysmal atrial fibrillation)
• J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation)
• I48.2 (Chronic atrial fibrillation)

Asthma

Classifications for asthma in ICD-10 are based on severity (mild, moderate or severe), and subcategories also differentiate between intermittent or persistent asthma as well as acute exacerbation, status asthmaticus or uncomplicated asthma.

Examples:

• J45.909 (Unspecified asthma, uncomplicated (asthma not otherwise specified)
• J45.22 (Mild intermittent asthma with status asthmaticus)

Altered Mental Status

Altered mental status can be further defined by the specific mental condition.

Examples:

• R41.81 (Age-related cognitive decline)
• R41.3 (Other amnesia [memory loss])
• R41.840 (Attention and concentration deficit)
• R40.4 (Transient alteration of awareness)
• R40.1 (Stupor)

Migraine

In order to code to the most specific level in ICD-10 for migraine headaches, some level of detail is necessary. Here are some examples of the different types of migraine codes available in ICD-10:

Examples:

• G43.001 (Migraine without aura, not intractable, with status migrainosus)
• G43.711 (Chronic migraine without aura, intractable, with status migrainosus)

Sepsis

Sepsis is another common ED diagnosis where the organism is not usually known at the time of the visit. Document the organism if it is known. Also document if the sepsis has progressed such as: severe sepsis, with or without septic shock.

Providers should continue to document any associated signs and symptoms that the patient presents with.

Important tip: The term “urosepsis” is considered a nonspecific term in ICD-10 and is neither recognized nor considered synonymous with sepsis. There is no default for “urosepsis” in ICD-10 and if the provider documents no other diagnosis or sign or symptom, then the provider will have to be queried for clarification.

Examples:

• A40.1 (Sepsis due to streptococcus, group B)
• A41.50 (Gram-negative sepsis, unspecified)
• R65.20 (Severe sepsis without septic shock)