Otolaryngology Coding Alert

Question: Does the CPT^® code determine the reimbursement rate or does the ICD-10 code? I thought it was the CPT^® code, but I keep hearing that our ENT practice’s pay could suffer if we don’t use the right ICD-10 codes, so I’m confused.

New Hampshire Subscriber

Answer: The CPT^® code on your claim determines your reimbursement rates under Part B Medicare.

On the other hand, ICD-10-CM codes support medical necessity for every procedure code on your claim — without them, insurers can’t justify paying you for the services your physician performs. Therefore, if you use nonspecific or incorrect diagnosis codes, your pay definitely could suffer, because your insurer might determine you didn’t perform a medically necessary service and you therefore aren’t entitled to payment for it.

Sometimes an ICD-10 code will be the cause of non-payment, however, such as when as an asymptomatic Medicare patient and her son make a visit prior to a hearing screen to discuss what will happen at the visit. In this case, reporting the screening code (such as Z01.10) would not be a Medicare-covered service. The patient could be held to pay for the visit by use of an Advanced Beneficiary Notice (ABN).

CMS pays Medicare Advantage (MA) payers based on their beneficiaries’ ICD-10 codes, which providers assign. The Medicare Advantage payers are sharing risk with CMS, and they are paid based on the Risk Adjustment that the patients’ diagnoses determine. The MA payers get paid more for patients that are sicker based on the diagnoses, and are paid less if the patients are healthier. Some experts believe that eventually, CMS is going to move away from paying providers for every procedure and service, and pay individual providers similarly to how the MA insurance companies are currently paid, based on Risk Adjustment. If that happened, CMS would have to make changes for smaller practices, as they won’t have the high numbers of patients to even out risk to the organizations that an insurer enjoys. Large practices are making sure their ICD-10 coding is accurate because even if this change does not happen, there could be bonus clauses written into contracts with payers based on the reporting of patients’ risk adjustment in the future.