Radiology Coding Alert

ICD-10 may have more specific options but not necessarily a one-to-one match.

If you want to know what payers are saying about the ICD-10 transition, you’ll do well to take a look at what National Government Services (NGS), a Medicare administrative contractor (MAC) in ten states, said to callers earlier this year; NGS used CMS advice to guide practices to smooth shifts from ICD-9 to ICD-10. Here are ten questions that were answered on the NGS call and what our experts have to say about the advice. 

1. Will we have to change our notice of privacy practices?

Only if you have specific ICD-9 codes on them, said NGS’s Alicia Forbes, CPC, on the call. For instance, if your privacy notice is so specific that it states, “Please list the names and phone numbers of any family members with whom we can discuss your breast cancer (ICD-9 code 174.1, Malignant neoplasm of central portion of female breast),” this would have to be changed to the appropriate ICD-10 code, such as C50.111 (Malignant neoplasm of central portion of right female breast). 

“Practices will need to revise their HIPAA notifications to fit the higher level of specificity as more information will be shared under ICD-10-CM,” says Christy Hembree, CPC, Team Leader, Summit Radiology Services, Cartersville, GA.

2. Does the CPT® code determine the reimbursement rate or does the ICD-9 code? And if it’s the ICD-9 code, will reimbursement rates change under ICD-10?

The CPT® code on your claim determines your reimbursement rates under Part B Medicare. Therefore, the appropriate ICD-10 codes will have to be linked to the CPT® codes on your claims, but the payments won’t be based on the specific ICD-10 codes used, Forbes said. 

“The CPT® code determines the reimbursement rate and has an associated fee on the fee schedule. The ICD-10 code supports the CPT® code and shows medical necessity,” Hembree says.

3. If reimbursement is based on CPT® codes, then how is ICD-10 going to make reimbursement more accurate, as Part B payers keep saying it will?

ICD-10 codes are more specific than ICD-9 codes have been, so Part B payers will be able to gather more information from the diagnosis codes up-front. This will lead to fewer chances of errors occurring during claims processing and will help prevent payers from having to halt the claims process for medical review personnel to review them line by line, said NGS’s Arlene Dunphy, CPC, during the call. 

“In order to reimburse for a procedure a payer needs to know why the procedure was performed and ensure it is reasonable and necessary,” Hembree says. “The ICD-10 code supports medical necessity. It tells the payer why the procedure or exam was performed. If proper medical necessity is not given you risk no reimbursement for the procedure. ICD-10 is very specific and gives a great deal of detail about a patient’s condition. ICD-10 should allow us to give a lot more specific information to a payer to explain why a procedure is being performed.”

4. Do we have to contact our payers this fall to see if they’re ready to accept ICD-10 claims?

No. Effective from the date of implementation, all Medicare payers will begin accepting these codes, so you don’t need approval for them. When it comes to testing, however, your payers will let you know when their individual testing dates are.

“On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, 2015,” Hembree says. “Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015. It is not a bad idea to contact your non covered HIPAA entities. They are not required to delay ICD-10. Non-covered HIPAA entities are mainly workers comp and auto insurance along with a few other payers. Also, keep in mind some payers are still actively testing and you should stay in contact to make sure you do not miss your testing periods.”

5. If there are no updates scheduled for the ICD-10 code set between Oct. 1, 2013, and Oct. 1, 2014, does that mean that it’s safe to buy the book now, since there won’t be any new codes added to it this October?

There will be limited code updates for the Oct. 1. 2014, date, so there may be some changes to the newest book that apply to ICD-10 as of this coming October, Dunphy said. Therefore, if you only want to buy the book once this year, you may want to wait until the edition is released that includes any codes introduced this year. 

“Although regular scheduled updates will not take place there is still the possibility for minor change. Revisions to ICD-10-CM/PCS may include new codes for new diseases/new technology procedures, and any minor revisions to correct reported errors in these classifications,” Hembree says.

6. When will the updated LCDs be available?

The local coverage decisions (LCDs) that will include ICD-10 codes will be posted by April 10, Dunphy said. Some MACs may have already started posting updates to LCDs, but they are supposed to have all LCDs updated by April 10 at the latest, according to MLN Matters article MM8348. 

“LCDs for ICD-10 codes are currently published on the CMS website under “Future LCDs/Future contract number LCDs,” Hembree says.

7. How much readiness is required of a biller whose coders and doctors do all the coding on their own?

A biller has to have some knowledge of ICD-10, because if the physician or other practitioner has unclear handwriting, you’ll still need to know enough about ICD-10 to look up codes in the book, Forbes said.

In addition, sometimes the coder will leave out the placeholder codes of “xxx” and you’d have to know the ICD-10 coding conventions to be able to recognize when the placeholder x’s aren’t in place, Forbes added. 

According to Hembree, “A great deal of preparation is needed to make the ICD-10 transition smooth. ICD-10 changes everything. Pre-certs will need to be taken in to consideration in the months leading up to ICD-10, orders, and every additional aspect of the office where ICD-9 codes are currently used.”

8. For ICD-9 to ICD-10 mappings that aren’t one-to-one, isn’t it always best practice to use the ICD-10 code that says “unspecified?”

Unless the clinical documentation is nonspecific, then you should select the most specific code based on the documentation rather than just randomly choosing the nonspecific code, Forbes said. 

“You should always code to the highest degree of certainty. A code is invalid if it is not coded to the highest level of specificity,” Hembree says.

9. We’re a small office using paper claims. Can we use ICD-9 codes on the new claim forms beginning April 1 through Sept. 30 this year?

Yes, the new CMS-1500 form (version 02/12) will be the only paper claim form accepted as of April 1, so you will be able to use ICD-9 codes on these forms from April through dates of service at the end of September, Forbes said. 

This form will accommodate ICD-10 codes effective Oct. 1, so you can use the same form then. However, don’t try submitting ICD-10 codes before Oct. 1 — systems won’t be able to process ICD-10 codes until dates of service on or after Oct. 1, 2014.

10. An ICD-10 acknowledgment testing week was scheduled for March 3-7, 2014. Is there a chance that Medicare will offer additional testing date later this year?

Medicare will provide another opportunity for practices to test their submission of ICD-10 codes in May, according to Medicare Learning Network (MLN) Matters article SE1409. The same article also indicates that Medicare intends to offer end-to-end testing with ICD-10 in late July 2014 to a small sample group of providers. 

End-to-end testing tracks a claim from initial connectivity and claim submittal all the way through remittance advice, denials, and refund requests. CMS will select more than 500 volunteer submitters for the project, choosing a broad cross-section of providers, suppliers, and other submitters and claims types. CMS will provide information on volunteering later this month and disseminate additional details about the test in a separate MLN Matters article.