ED Coding and Reimbursement Alert

With all the rush by emergency departments (ED) in hospitals to brace for ambulatory payment classifications (APCs), few coders or emergency department clinicians have taken the time to check out the 2001 revisions to ICD-9 codes, which take effect Oct. 1. Some of the Health Care Financing Administration (HCFA) changes will require the inclusion of more information. These new codes will force coders to change how they code, and will require doctors to change how they document some services.

HCFA didnt make the annual ICD-9 changes for fiscal year 2000 because it didnt want to conflict with possible year 2000 computer problems, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. So this year, they announced a rather long list of the new codes for 2001, which incorporated the proposed changes for the past two years.

Many of these codes will affect the emergency department directly. The best way for coders to effectively integrate the new codes is to familiarize themselves with them before they take effect. To learn what codes have changes, read the May 5, 2000, edition of the Federal Register at www.access.gpo.gov/su_docs/fedreg/ a000505c.html, and start at page 26,382. Fewer than 200 codes are being added, removed or changed.

ED coders should know about the following changes:

The 493 asthma series has been expanded, adding fifth digits to 493.0, 493.1, 493.2 and 493.9 to delineate exacerbation. For example, 493.1 now stands for intrinsic asthma. Under the revision, 493.12 stands for intrinsic asthma, with acute
exacerbation. Code 494 for bronchiectasis also has received exacerbation modifiers.

Ulcer of lower limbs, 707.1, has been expanded, with fifth digits added to specify the location of
the ulcer.

Codes have been added for such symptoms, signs and ill-defined conditions as loss of height (781.91), abnormal posture (781.92), failure to thrive (783.41) and short stature (783.43).

V codes for allergies have been expanded, adding a fifth digit to V15.0 to signify substances such as peanuts, milk products, insects and latex.

V codes for acquired absence of organs also have been expanded, adding a fifth digit to specify which organ is missing.

These changes add versatility to the ICD-9 system, and Donna Savard, RHIA, medical records director at Mackinac Straits Hospital and Health Center in St. Ignace, Mich., appreciates that kind of change. I would hope there are many changes. I hope it would give you more to choose from to help you solve the puzzle.

Traditionally, HCFA and the National Center for Health Statistics dont make major changes every year, says Barbara Cole, RN, BSN, CPC, vice president of pre-billing operations at Reimbursement Technologies, a Conshohocken, Pa., billing and financial management company for emergency physicians. There have been years when theyve broken out new codes to make them more specific, or added new codes, but its not normally like CPT changes.

Because the changes arent drastic, theres no need for extensive training for coders, she says. A small in-service meeting or a memo for coders should do the trick, along with modifications to end-coder software.

But emergency departments should take two steps to prepare themselves for the new codes:

1. ED coding supervisors should go through the new codes with a charge ticket or chart, according to Barbara Cobuzzi, CPC, CPC-H, MBA, CHBME, president of Cash Flow Solutions, a Lakewood, N.J., financial consulting company for healthcare professionals. Either way, you have to make sure youre up to date.

2. Because of the requirements for greater specificity, such as the case with ulcers of the lower limbs, doctors must provide information that normally may not make it onto the record, she says. If your ED physicians dont already document the new information required by the ICD-9 revisions, they will need to learn the new rules.

Although the revisions officially take effect on Oct. 1, coders cant unilaterally switch over then. Many payers wont have them in place until after Jan. 1, Cobuzzi says. You can start using these new codes, and maybe your Medicare carrier has it in place. (Private payers) may not be ready.

How can coders deal with the discrepancy? Trial and error, Cobuzzi says. They must be prepared to resubmit bills using the old system for payers who arent caught up on the ICD-9 revisions.

Coders or clinicians interested in more information regarding the codes to help them prepare for the coming changes should, in addition to reviewing the codes in the Federal Register, read the minutes of the meetings at which the changes were discussed. These minutes offer valuable insights into the reasons behind the changes.

Information on procedure code changes can be found at www.hcfa.gov/medicare/icd9cm.htm. For information on diagnosis code changes, go to www.cdc.gov/nchs/ about/otheract/icd9/maint/maint.htm.

ICD-10 Revisions Will Change Everything Maybe Although the latest ICD-9 codes have not officially been enacted yet, the Health Care Financing Administration (HCFA) already is reviewing ICD-10. This new coding system, now used in other countries, would replace the current system of 13,000 codes with a new, more detailed system of 60,000 codes, according to Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. The new system cant start until 2003 at the earliest, according to Tanesha Brady, RHIA, coding supervisor at Reimbursement Technologies, a billing and financial management company for emergency physicians in Conshohocken, Pa., because these changes usually require a 24-month lead-in period. So should coders be concerned? They shouldnt be worried, but should be concerned enough to learn all they can about the changes and prepare for their implementation. The new system, which completely overhauls the ICD-9 methodology, contains so many changes that the government will allow providers more time than usual to prepare. Here are some of the major highlights of the plan as it now stands: It will use a system of six-character alphanumeric codes, scrapping the five-digit codes used now. The basic identification system will change. ICD-10 will require coders looking for the code for a hand injury to look up hand, then find the injury. This reverses the operation of the current system. All codes will include laterality, or specification of left or right, or open or closed. ICD-10 also contains a new coding system for procedures, called ICD-10-PCS, Callaway-Stradley says. This new system would replace the third volume of ICD-9-CM, which is not now used for physician or outpatient coding. But potentially, CD-10-PCS could be used for both. Regardless of the details of the final product, There will be quite a large learning curve for coders used to using ICD-9, Brady says. To further complicate matters, ICD-10 isnt the only potential change in the works for the coding industry. The American Medical Association is working on CPT-5, which would replace CPT-4. HCFA hasnt yet determined which system to use, and may not make that decision for some time. For more information about the CPT-5 system, visit www.ama-assn.org/med-sci/cpt/cpt5.htm. Information about the ICD-10 system is available at www.cdc.gov/nchs/ about/major/dvs/icd10des.htm.