ICD 10 Coding Alert

Hint: The code changes may affect patients’ physical status modifiers.

CMS has released the 2021 diagnosis code changes, which go into effect Oct. 1, 2020. This year’s update includes 730 changes: 613 new additions, 52 revisions, 26 deletions, and 39 existing diagnoses converted to parent codes.

Dive into the code additions and revisions now so you don’t compromise your coding accuracy come October.

See How These Changes Affect Patient Status

Some of the changes could affect your coding, especially those related to conditions that could affect which physical status modifier is assigned to the patient. Consider these examples:

• Diagnosis N18.3 (Chronic kidney disease, stage 3 (moderate)) converts to a parent code. Three new subcodes add specificity:
  • N18.30 (Chronic kidney disease, stage 3 unspecified)
  • N18.31 (Chronic kidney disease, stage 3a)
  • N18.32 (Chronic kidney disease, stage 3b)

• Diagnosis O99.89 (Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium) becomes a parent code with two new subcodes of interest to anesthesia providers:
  • O99.891 (Other specified diseases and conditions complicating pregnancy)
  • O99.892 (Other specified diseases and conditions complicating childbirth)

Also note: Diagnoses related to body mass index (BMI) under code family Z68 (Body mass index [BMI]) are designated as being revised for the new edition. The code descriptors actually remain the same (such as Z68.1, Body mass index [BMI] 19.9 or less, adult). The revision lies in setting aside the “BMI” abbreviation with brackets instead of parentheses. These changes apply to diagnoses for adult and pediatric patients from Z68.1 through Z68.54 (Body mass index [BMI] pediatric, greater than or equal to 95th percentile for age).

Understand When Diagnoses Justify Anesthesia

“As a general rule, anesthesia doesn’t provide any more diagnosis codes than are necessary to report the reason for the surgery,” says Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. “Exceptions to this are when diagnoses help support a physical status code on a private insurance claim or when the diagnosis supports the use of MAC (monitored anesthesia care) for either private insurance or Medicare if medical necessity for anesthesia is in question.”

However: Anesthesia providers assign physical status modifiers to every claim, designating the patient’s general category of health. This can come into play because certain physical conditions can increase the risk of administering anesthesia.

For example, when the new diagnosis codes mentioned above are assigned to a patient’s case, these codes for more serious disease or complications could lead to the anesthesia provider assigning a higher-level physical status code. That, in turn, might lead to additional reimbursement for the anesthesia provider because of additional risk when caring for the patient.

Although the modifiers primarily are used for documentation purposes, some insurers might pay additional units to providers for higher-acuity patient statuses. (Medicare will not pay for any physical status modifiers.) The physical status modifiers are:

• P1 (A normal healthy patient)
• P2 (A patient with mild systemic disease)
• P3 (A patient with severe systemic disease)
• P4 (A patient with severe systemic disease that is a constant threat to life)
• P5 (A moribund patient who is not expected to survive without the operation)
• P6 (A declared brain-dead patient whose organs are being removed for donor purposes)

Anesthesia providers assign the patient’s physical status modifier during the pre-anesthesia assessment. Having broad-based descriptors for P modifiers is intentional, so they can easily apply to any scenario.

Remember This Guidance

The following examples can serve as a guide to patients’ conditions when you study your own providers’ cases:

• P1 is generally a healthy patient who presents to the anesthesiologist with minimal risks for the procedure in question.
• P2 applies to patients with mild systemic conditions such as controlled diabetes.
• P3 applies to patients who have a severe systemic disease that could potentially kill them, such as severe diabetes with vascular complications, stable angina, or lupus. However, the patient is expected to do well in surgery despite the health condition.
• P4 represents a patient whose systemic disease is a higher-level threat, such as unstable angina or congestive heart failure. They aren’t expected to die during the perioperative period, though having the disease means it wouldn’t be totally unexpected if it happened.
• P5 represents a very high risk, sick patient or one in a trauma situation. Modifier P5 can apply to patients with severe conditions such as a ruptured aneurysm or major cerebral trauma with rapidly increasing intracranial shock. Performing surgery on this patient could go one way or the other — life or death — but the patient will likely die without the surgery.
• P6 is for patients who are not eligible for a physical status risk increase as their organs are being kept viable for harvesting.

“My rule of thumb is that if the coder cannot find a specific policy, she should report physical status modifiers, with the exception of traditional Medicare,” Dennis says. “Insurance cannot pay for a service that isn’t reported.”