Wiki Icd 10 and justification for e&m codes

[wandasw]

There are instances especially in a primary care practice when a patient is being seen for many chronic conditions. The provider is using the "status of 3+ chronic conditions" in his determination of the E&M level to bill. However, there are times where the patient has DM II w/ CKD and is insulin dependent. The provider considers this "1" condition. ICD 10 requires we use 3 codes to describe this condition, E11.22, N18._ and Z79.4. Now he also needs to report more of the chronic conditions in order to justify his 99204 or 99214. There are many other conditions in ICD 10 that require 3 or more codes to describe 1 condition

I am fully aware that 12 diagnosis codes can be reported on an electronic claim, but only 4 of those can be linked to any cpt code. That means that 3 of the 4 that will be linked to the E&M code are taken up with 1 condition leaving only 1 other that can be linked to the E&M. Two chronic conditions would not justify the 99214 or 99204. Certainly we can type in the other diagnosis codes, but they're not going to be linked to any cpt code so what good would that do.

What are we supposed to do in this type of situation? Please help!!!

 

[wandasw]

The provider is concerned about the DX codes justifying the level 4 visits when the HPI is "status of 3+ chronic conditions". For example, the patient comes in for followup or to establish care with DX of Insulin Dependent DMII w/CKD, OA and COPD.

He addresses all 3 conditions and documents accordingly. When we post the charge, we're going to bill 99214 or 99204 based on his documentation, yet we CAN ONLY LINK 4 DX CODES to the office visit with the DX Pointers per the 5010 electronic claim format. So if we use the DMII w/CKD, insulin dependent, we must report 3 separate DX diagnosis codes to describe that one condition. We can only link one of the other two OA or COPD to the visit. We can type in the other DX code, but it's not going to be linked to the visit to support the extended HPI required for detailed history for level 4 visit.

With the ICD10 instructions for using all 3 of those DX codes to report 1 condition, how can we report all the codes to justify our E&M level? I realize that the "documentation" does support the level, but it's not really showing up on the actual claim. Up to 12 DX codes can be input, but since only 4 can be "Pointed" to any service, what good does it do to enter them?

Maybe we're over-thinking this, but the doctor and I both agree that this is a problem.

Does anyone have any input?? Thanks

 

[mitchellde]

How did you do this prior to Oct 1? This is no different from ICD-9 for this example. It took three codes in ICD-9 CM for the type II insulin dependent diabetic CKD and it takes three codes in ICD-10 CM. So has this always been an issue is my question or is it suddenly an issue and if so why?