Optometry Coding & Billing Alert

You’ve got three months left to simply code in the right ‘family.’

If the ICD-10 transition almost seemed too easy for your practice, that could be because you have a false sense of security thanks to CMS’s “grace period.” Unfortunately, however, that is about to end, which could result in a new mountain of denials for your eye specialist’s claims.

Here’s why: Nearly a year ago, CMS announced that it would implement a grace period for the ICD-10 rollout, assuring practices that MACs would not deny claims with the wrong ICD-10 codes, as long as the codes were from the right “family.” Although this announcement gave practices a temporary reprieve on the ICD-10 denials they were anticipating as of Oct. 1, 2015, that reprieve is about to expire, so now is the time to ensure that your ICD-10 codes are as accurate as possible.

The grace period ends on Sept. 30, and there’s a strong chance that denials will increase thereafter, says Monica Smith, RHIT, CPC, CRCR, an associate in Kraft Healthcare Consulting’s compliance services division and an ICD-10 trainer. “Physician offices aren’t used to the specificity that is required for ICD-10.”

You’ve still got time to re-invigorate your ICD-10 training and maintenance programs before the grace period ends. The following tips will help ensure that you’re on the right track to successfully collect for your services.

1. Don’t Be Vague

If you haven’t yet brushed up on ICD-10’s specificity requirements, now is the time. “Physicians need to state the diagnosis as specifically as they can, being sure to link conditions if needed,” Smith advises. “If the conditions are specific, then the other issues will not be a problem.”

For example, simply documenting “Senile cataract” will not be sufficient. You’ll need to know whether the cataract was incipient, anterior, posterior, cortical, nuclear, etc. In addition, you’ll need to know which eye was addressed. The procedures supported by H25.031 (Anterior subcapsular polar age-related cataract, right eye) may be completely different from those supported by H25.10 (Age-related nuclear cataract, unspecified eye), for example.

In addition, Smith advises, always link conditions if applicable. “Be specific, document it — if it’s not written, it can’t be coded.” She advises practices to review the updates every Oct. 1 so you don’t miss any new, revised or deleted codes.

For example, the age-related macular degeneration codes will change dramatically starting this October, with the deletion of existing codes H35.31-H35.32 and the introduction of expanded codes such as H35.3110 (Nonexudative age-related macular degeneration, right eye, stage unspecified).

2. List All Treated Diagnoses

When assigning ICD-10 codes, you should first code the main or most serious diagnosis, which is typically determined as follows:

• The primary reason for the encounter, or
• The condition with the highest risk of morbidity/ mortality that the physician is addressing at the encounter.

After the primary diagnosis, you’ll then list additional diagnoses describing other conditions that the patient has as well. “Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management,” the ICD-10 manual states. “Do not code conditions that were previously treated and no longer exist. However, history codes (Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.”

3. Brush up on the Rules

The ICD-10-CM code set is not just a list of codes — it also comes with a 115-page list of rules titled “ICD-10-CM Official Guidelines for Coding and Reporting FY 2016.”

In this document, you’ll find scores of tips that help you choose the most appropriate code based on the condition you’re treating. For instance, the 2016 guidelines offer the following advice on how to code when a patient has different types of glaucoma in each eye:

“When a patient has bilateral glaucoma and each eye is documented as having a different type or stage, and the classification distinguishes laterality, assign the appropriate code for each eye rather than the code for bilateral glaucoma,” the Guidelines say. “When a patient has bilateral glaucoma and each eye is documented as having a different type, and the classification does not distinguish laterality (i.e. subcategories H40.10, H40.11 and H40.20), assign one code for each type of glaucoma with the appropriate seventh character for the stage.”

If, however, the patient has bilateral glaucoma represented by the same type in each eye but different stages and the classification does not distinguish laterality (i.e. subcategories H40.10, H40.11 and H40.20), “assign a code for the type of glaucoma for each eye with the seventh character for the specific glaucoma stage documented for each eye,” the guidelines advise.

Resource: For more on the guidelines, visit www.cms.gov/medicare/coding/icd10/downloads/2016-icd-10-cm-guidelines.pdf.