Medicare Compliance & Reimbursement

Tip: Know your diagnosis options for E/M codes 99497 and +99498.

Whether you like it or not, the 2018 changes to ICD-10 are already in effect. It's time to utilize your options and add the extra depth to your coding that diagnosis codes offer.

Take a look at these five patient problems - and the answers on how to code them.

Question 1: What is important to note about coding comorbid conditions?

Answer 1: It can be confusing to see scores of diagnosis codes in a patient's chart, but knowing the order in which you should report them is essential to accurate coding, expert coder Sharon Nicka, RN, CPC, of Nicka & Associates in McKinney, Texas says. For instance, suppose a patient with a history of breastcancer and existing glaucoma comes in with a fractured leg.

"Sequencing is so important, and you have to ask yourself why the patient came to the ED [emergency department]," Nicka says. "In this case, it was a fractured leg. The comorbidities will make a difference on how that patient is treated and managed, and with ICD-10, you need great detail, so code those comorbidities after the current diagnosis if they are documented as relevant to the ED encounter."

In black and white: "For outpatient claims, providers report the full diagnosis code for the diagnosis shown to be chiefly responsible for the outpatient services," CMS says in Section 10.3 of Chapter 23 of the Medicare Claims Processing Manual.

"For instance," the Manual says, "if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported. If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported."

Question 2: Do you code for the symptoms or for the diagnosis for respiratory distress?

Answer 2: Initial encounters with patients suffering from respiratory distress often don't conclude with an authoritative diagnosis, which means you will often end up bypassing the J00-J99 (Diseases of the Respiratory System) codes in favor of choosing a sign or symptom from the R00-R09 (Symptoms and signs involving the circulatory and respiratory systems) code block.

But be careful when you do, as some symptom and sign codes that look like respiratory conditions may not be so. For example, Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, points out "You would only use R07.0 (Pain in throat) if the pain could not be identified as a disease relating to the respiratory system." Otherwise, you would use a more specific diagnosis, such as J31.2 (Chronic pharyngitis) or J02.9 (Acute pharyngitis, unspecified).

Similarly, Johnson maintains, you would only use R06.2 (Wheezing) "if any of the respiratory system disease codes such as J44- (Other chronic obstructive pulmonary disease), J45- (Asthma), or any of the J40-42 bronchitis codes are not warranted."

Question 3: What ICD-10 codes can you report with 99497 and +99498?

Answer 3: You report advance care planning (ACP) with codes 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms [with completion of such forms, when performed], by the physician or other qualified healthcare professional; first 30 minutes, face-to-face with the patient, family member[s], and/or surrogate) and +99498 (... each additional 30 minutes [List separately in addition to code for primary procedure]).

While you won't find any diagnosis requirements for 99497 and +99498, you could report the chronic condition that initiated the ACP, according to Najwa N. Liscombe, BHSA, CPC-CPC-I, CMA, coding reimbursement analyst III at the University of Florida College of Medicine and Community Health and Family Medicine in Gainesville, Florida.

Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Florida, agrees that you will probably usethe diagnosis of whatever chronic illness the patienthas.

"If you do ACP in conjunction with the annual wellness visit, then it's probably going to follow with the diagnoses of the annual wellness visit," Mac adds.

According to JoAnne Sheehan, CPC, CPB, CPPM, COC, CPC-I senior instructor/coach at Certification Coaching Organization, LLC in Oceanville, New Jersey, you should link diagnoses to the ACP supporting the need for ACP, if applicable, or use a preventive diagnosis code with the preventive visit.

Question 4: What new ICD-10 codes impact Apnea?

Answer 4: You will want to take note of two specific changes when coding apnea of any specified nature. Primary central sleep apnea now comes with an idiopathic label, when documented, along with the addition of an entirely new diagnosis code for hypopnea. With the addition of code G47.31 31 (Primary central sleep apnea), you will want to make sure you are fluent with the rules on when and when not to code a disease as idiopathic.

"Only when the physician includes the term 'idiopathic' in their diagnosis should you apply code G47.31," states Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. "When there is no documentation of 'idiopathic' primary sleep apnea, you will want to default to the unspecified code, G47.30 (Sleep apnea, unspecified).

"Do not make the false assumption that a lack of documented etiology implies that the disease is of an idiopathic origin," Della Vella instructs. You will find these two new codes under "Apnea, apneic (of) (spells)" in the ICD-10 index.

Important: Apnea, apneic (of) (spells)

Sleep ⇒ central (primary) ⇒

• G47.31 (Idiopathic central [primary] sleep apnea)

Sleep ⇒ obstructive (adult) (pediatric) ⇒

• G47.33 (Hypopnea)

Question 5: What does "necrosis" mean, and why is it important?

Answer 5: Some of the new non-pressure chronic ulcer codes specify that the ulcer is "without evidence of necrosis," which gives a clearer picture of the patient's health.

Necrosis refers to how healthy a wound is, and it points to a likely inadequate perfusion to the wound (vascular issue), according to Jordan Meyers, DPM, partner at Raleigh Foot and Ankle Center and consultant at Treace Medical Concepts, Inc. in Raleigh, North Carolina.

"Knowing if there is a sign of necrosis impacts how the podiatrist will treat the ulcer," notes Arnold Beresh, DPM, CPC, CSFAC in Newport News, Virginia.

Beresh adds, "If there isn't a sign of necrosis, the podiatrist doesn't have anything to debride as per the debridement codes' definition." So, in that case, the correct treatment would just be wound care.