Coding & Reimbursement

Ready or not, ICD-10-CM updates are here

By Suzanne L. Corcoran

ICD-10 went into full effect on Oct. 1, 2015, but the challenges it poses aren’t over yet: This year there are major updates, and a lot of new codes. On Oct. 1, 2016, the first update in five years of ICD-10-CM diagnosis codes gave us 1,974 new codes, 311 deleted codes and 425 revised codes. In addition to code changes, some tabular instructions were revised to provide clarity. Here are some important changes you need to know.

Q. What changes can we expect for glaucoma?

A. As expected, laterality was added to open-angle glaucoma, H40.11x _. The sixth digit now specifies which eye, replacing the placeholder “x”. The seventh digit remains the stage of glaucoma. For example: prior to Oct. 1, 2016, a patient with primary open-angle glaucoma, moderate stage, in the left eye was coded as H40.11x2. After Oct. 1, 2016, it will be coded as H40.1122. The “2” in the sixth place designates the left eye.

Q. What should we expect when coding for AMD?

A. When originally published, dry AMD — regardless of which eye — was coded as H35.31. Wet AMD was coded as H35.32, again without specifying which eye. The update effective Oct. 1, 2016 adds laterality and also adds “staging”. The eye will be indicated by the sixth digit in the ICD-10 code, and the stage of AMD will be the seventh digit.

Q. How are the stage codes described for dry AMD?

A. There are five stages, including unspecified, listed for dry AMD.

0 - stage unspecified

1 - early dry stage

2 - intermediate dry stage

3 - advanced atrophic without subfoveal involvement advanced dry stage

4 - advanced atrophic with subfoveal involvement

The seventh character, the stage, of the ICD-10 code for dry AMD will be 0 to 4.

For example: H35.3112, nonexudative AMD, right eye, intermediate stage. The sixth digit “1” indicates the right eye, and the seventh digit “2” represents intermediate stage.

Q. Does the same approach apply to wet AMD?

A. Yes, but with some variation. The sixth digit will be for laterality but with only four stages including an unspecified stage for wet AMD.

0 - stage unspecified

1 - with active choroidal neovascularization

2 - with inactive choroidal neovascularization with involuted or regressed neovascularization

3 - with inactive scar

The seventh character, the stage, of the ICD-10 code for wet AMD will be 0 to 3.

For example: H35.3221 describes a patient with exudative AMD, with active CNV in the left eye. The sixth digit “2” indicates the left eye, and the seventh digit “1” indicates active CNV stage.

Several classifications of AMD are available in various publications. The American Academy of Ophthalmology uses the Age Related Eye Disease Study (AREDS) to classify AMD. You can find it in the Academy’s Preferred Practice Patterns document on Age-Related Macular Degeneration.

Q. Are there changes to diabetes coding?

A. Yes — approximately 260 new diabetic combination codes. Most importantly, laterality is now in place; it is noted by the seventh character. Some examples include:

• Diabetic retinopathy codes added laterality, changing them from six to seven digits

○ E11.3293 (Type 2 DM, mild NPDR, no DME, bilateral)

• New diabetic codes including other retinal disease and resolved disease

○ E11.3531 (Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye)

○ E11.3552 (Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye)

○ E10.37x3 (Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral)

You know that there is a code to indicate current long-term use of insulin — Z79.4. Now, a code to indicate current long-term use of oral hypoglycemic drugs has been added — Z79.84. Unchanged is the instruction to code E11- for type 2 diabetes mellitus if the medical record does not indicate the type of diabetes but does indicate that the patient uses insulin.

Q. What about combination codes?

A. Combination codes are single codes that classify two diagnoses. Multiple codes are not used when a combination code clearly identifies all the elements of a diagnosis. Accurate chart documentation is critical to accurate code selection. For example:

• Diagnosis with an associated manifestation

○ E11.3211 (type 2 DM with mild nonproliferative diabetic retinopathy with macular edema, right eye)

• Diagnosis with an associated complication

○ H59.032 (cystoid macular edema following cataract surgery, left eye)

Q. Are there other new codes?

A. Yes, including a new series of codes to describe postprocedural diagnoses for hematoma and seroma. Laterality is noted as a sixth digit.

• H59.33- (Postprocedural hematoma of eye and adnexa following an ophthalmic procedure)

• H59.34- (Postprocedural hematoma of eye and adnexa following other procedure)

• H59.35- (Postprocedural seroma of eye and adnexa following an ophthalmic procedure)

• H59.36- (Postprocedural seroma of eye and adnexa following other procedure)

There is also an expanded code series to describe amblyopia suspect: H53.04-.

Q. What types of changes were made to the instructions to provide more clarity?

A. There were several welcome changes. The instructions regarding etiology/manifestation note that an underlying condition should only be coded when it is applicable. There has been confusion about how to code some diagnoses when there was no underlying condition.

Confusion about applying laterality, however, has been resolved. Basically, it says you may use the bilateral code when both eyes have the same condition, even if only one eye is being treated. We believe this is appropriate for exams, but likely not for surgery. For example, if a patient has bilateral cataracts, it makes sense to code as such for the exam, but you should continue to code right eye or left eye for the surgery.

A point of confusion from the outset of ICD-10 has been the “Excludes 1” and “Excludes 2” designations. Some conditions with an “Excludes 1” notation could also have a second condition, but the “Excludes 1” note did not permit using both codes. In the updated manual, some “Excludes 1” notes were changed to “Excludes 2” notes, allowing for some conditions previously disallowed by the “Excludes 1” note to now be coded together. For example, ICD-10 code H42, Glaucoma in diseases classified elsewhere, could not be coded along with diabetes; the update removes that exclusion.

In addition, for physicians who treat newborns, a revised guideline addresses evaluation involving a suspected condition not found or ruled out. It says, “Assign a code from category Z05, Observation and evaluation of newborns and infants for suspected conditions ruled out, to identify those instances when a healthy newborn is evaluated for a suspected condition that is determined after study not to be present. Do not use a code from category Z05 when the patient has identified signs or symptoms of a suspected problem; in such cases code the sign or symptom.”

Q. Will CMS continue to allow use of nonspecific codes as long as we select from the right “family” of codes?

A. Very unlikely. In July 2015, CMS indicated that it would not deny or audit claims just for specificity for one year after ICD-10 implementation, as long as the billed code is from the appropriate “family of codes.” Most Medicare contractors accepted and paid claims with unspecified codes as long as the code was from the appropriate family. The “honeymoon period” ended Sept. 30, 2016. Now, you must eliminate use of unspecified codes when alternatives exist.

Q. What else should we consider with the implementation of these ICD-10 changes?

A. There are several things to monitor:

• Update your EMR and practice management system with the new codes

• Test the new ICD-10 codes with your clearinghouse

• Remember: some of the new codes replace others, and the latter will no longer be accepted on claims

• Train physicians and staff regarding the new codes

• Establish an internal audit program to ensure specificity

• Monitor coverage guidelines and Local Coverage Determinations by payers, and be prepared to contact them if new codes are not added to coverage policies.

Remember always that chart documentation is critical: Diagnoses cannot be accurately coded with inadequate charting. OM

REFERENCES

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.