Part B Insider (Multispecialty) Coding Alert

Hint: Two kinds of 'excludes' notes exist in ICD-10 aftercare codes.

While many coding conventions will remain the same as you make the transition from ICD-9 to ICD-10 in 2013, you'll need to be aware of a few crucial differences for accurate reporting. Get a head start on your ICD-10 readiness by checking out the following three changes you'll have to deal with starting on Oct. 1, 2013.

'Excludes' May Mean Two Different Things

One major change is that ICD-10 has two different types of "excludes" notes. While this might seem like another layer of complication in coding, it will actually clear up one of ICD-9's little quirks.

In ICD-9, an "excludes" note can have two different meanings. Excludes 1 means 'NOT CODED HERE.' As a matter of fact, you should never report the excluded code at the same time as the code above the Excludes 1 note. Excludes 1 means the 'two conditions cannot take place together'. Instead, an Excludes2 note tells you that the excluded term should be reported using another code. However if the patient has both conditions you may report both codes. In other words, when an Excludes2 note appears under a code it's acceptable to use both the code as well as the excluded code together.

Currently, some ICD-9 "excludes" notes indicate that you should never report a code for the excluded term in conjunction with the code you have located in the tabular list.

Example: An "excludes" note under V54.1 (Aftercare for healing traumatic fracture) indicates that this is not the correct code category for reporting aftercare following joint replacement surgery.

In ICD-10, this type of "excludes" note is labeled as "Excludes1." For example, ICD-10 code category Z47.- (Orthopedic aftercare) carries the note: "Excludes1: aftercare for healing fracture -- code to fracture with 7th character D."

In other instances, an ICD-9 "excludes" note can mean that you will need to list a second code in addition to the one you are considering if your patient has both conditions.

Example: ICD-9 subcategory V58.4 (Other aftercare following surgery) has an "excludes" note indicating that these codes do not cover attention to artificial openings. So if you were coding for a patient who had suffered a subdural hematoma during an automobile accident and also needed care and teaching for a new gastrostomy, you would list both V58.43 (Aftercare following surgery for injury and trauma) and V55.1 (Attention to gastrostomy).

In ICD-10, this type of "excludes" note is labeled as "Excludes 2." For example, category Z48 (Encounter for other postprocedural aftercare) lists an Excludes 2 note that reads "Excludes 2: encounter for attention to artificial openings (Z43.-) encounter for fitting and adjustment of prosthetic and other devices (Z44-Z46)." You would list these codes in addition to the Z48.- code if appropriate.

'X' Marks the Spot

When you receive your ICD-10 manual, you may see certain codes that include an "x" or an "x?" in them--but don't chalk it up to a printing error. The "x" in your code listing is actually there to help you.

Here's why: The "x" is actually a placeholder to remind you that another character should be inserted, said Sue Bowman, director of coding policy and compliance with AHIMA, during CMS's "Introduction to ICD-10- CM National Provider Call" last year. For instance, some codes are required to have seven characters to be valid, and the seventh character must appear in the seventh position (not simply the "last" code position). "Occasionally, a code that requires a seventh character is less than six characters long," Bowman noted. "In that case, a placeholder of 'x' is used to fill in the empty characters so the seventh character value can appear in the seventh character position."

For example: ICD-10 code V49.59x? (Passenger injured in collision with other motor vehicles in traffic accident) will be a new code to describe injured passengers in accidents under ICD-10, which you'll list after the codes for the patient's actual injuries.

You'll note that this code is followed by the characters "x?" That's because to bill this code, you'll need to add a seventh character in place of the question mark. You will select that seventh character from the following three options:

A -- Initial encounter

D -- Subsequent encounter

S -- Sequela

Your physicians must not only document the note clearly and completely as they have in the past, but they also must make clear whether the patient is being seen for an initial encounter, a subsequent encounter, or due to sequela (a condition that's a result of a prior medical issue).

Therefore, your final code choice for a passenger being seen for an initial motor vehicle encounter in which the patient was a passenger would be V49.59xA.

Keep An Eye (And Ear, Etc.) on Laterality

You may have heard news about the ICD-10 manual being substantially thicker than the ICD-9 book, but don't be alarmed--much of the book's additions are merely due to the fact that many codes will require you to denote whether the left side or right side was treated when dealing with certain anatomic areas (eyes, ears, hands, hands, feet, ovaries, etc.)

For example: Currently when you report acute atopic conjunctivitis, you report 372.05 (Acute atopic conjunctivitis). In the rare cases when insurers want to know which eye was affected, you append the right side (RT) or left side (LT) modifiers.

ICD-10 changes: Under ICD-10, you'll not only have to denote the specific type of conjunctivitis by using the accurate diagnosis code, but you'll also have to indicate which eye was affected. Therefore, an acute atopic conjunctivitis diagnosis could track to one of the following codes, depending on the eye affected:

• H10.10 -- Acute atopic conjunctivitis, unspecified eye
• H10.11 -- Acute atopic conjunctivitis, right eye
• H10.12 -- Acute atopic conjunctivitis, left eye
• H10.13 -- Acute atopic conjunctivitis, bilateral

Documentation: Your physicians should already be including the affected eye in their documentation. All you need to do as a coder to capture this already present information is to format your superbill to capture the additional anatomical information.