Medicare Compliance & Reimbursement

Look for a whole new code set for ‘underdosing’ in ICD-10.

The proverbial road to ICD-10 may not be paved in gold, but your road to deserved reimbursement can have a golden hue if you’re prepared for the major coding transition by Oct. 1, 2015. And part of your preparation should include reviewing the ICD-9 versus ICD-10 coding for your organization’s most-used codes.

CMS provides a good resource on its “Road to 10” website (www.roadto10.org) that illustrates some of the most commonly used codes and their ICD-10 changes by specialty. Here is just a sampling of the most-used codes in family practice that will experience significant changes in ICD-10:

1. Hypertension: In ICD-10, the concept of “benign or malignant” relating to hypertension no longer exists, and hypertension is defined as essential (primary), according to the Centers for Medicare & Medicaid Services (CMS). When documenting hypertension, you will need to include: 1) type (e.g., essential, secondary, etc.) and 2) causal relationship (e.g., renal, pulmonary, etc.). You will also need to document tobacco use or exposure. 

2. Asthma: ICD-10 has updated the terminology used to describe asthma to reflect the current clinical classification system, CMS says. When documenting asthma, you must include:

1. Cause — Exercise induced, cough variant, smoking-related, chemical or particulate cause, or occupational.

2. Severity — For persistent asthma patients, choose one of the following:

• Mild persistent
• Moderate persistent
• Severe persistent

3. Temporal factors — Acute, chronic, intermittent, persistent, status asthmaticus, or acute exacerbation.

3. Underdosing: This is a new concept and term in ICD-10, allowing you to identify when a patient is taking less of a medication than prescribed, CMS says. When documenting underdosing, you must include:

• Intentional, Unintentional, Noncompliance — Is the underdosing deliberate (e.g., patient refusal)?
• Reason — Why is the patient not taking the medication (e.g., financial hardship, age-related debility)?

4. Diabetes: Coding for diabetes mellitus has more specificity, with a combination of ICD-10 codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system, according to CMS. ICD-10 no longer uses the concept of “secondary diabetes mellitus,” but instead provides specific secondary options.

When documenting diabetes mellitus, include:

• Type — e.g., Type 1 or Type 2 disease, drug or chemical induced, due to underlying condition, gestational, etc.
• Complications — What (if any) other body systems are affected by the diabetes condition (e.g., foot ulcer related to diabetes mellitus)?
• Treatment — Is the patient on insulin?

In ICD-10, the concepts of “hypoglycemia” and “hyperglycemia” have changed. You can now document and code these conditions without using “diabetes mellitus” and specify if the condition is due to a procedure or other cause, CMS notes.

5. Injuries: When it comes to increased specificity under ICD-10, the new coding for injuries takes the cake. While ICD-9 used separate “E codes” to record external causes of injury, ICD-10 more thoroughly incorporates these codes and expands sections on poisonings and toxins, CMS notes. When documenting injuries, you should include:

• Episode of care — e.g., Initial, subsequent, sequelae.
• Injury site — Be as specific as possible.
• Etiology — How was the injury sustained (e.g., sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)?
• Place of occurrence — e.g., School, work, etc.

For initial encounters, you may also need to include (where appropriate):

• Intent — e.g., Unintentional or accidental, self-harm, etc.
• Status — e.g., Civilian, military, etc.