Diabetes in Real Life

Overcoming hurdles of ICD-10 diagnosis coding

In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with certified endocrine coder Mary Ann Hodorowicz, RDN, MBA, CDE, about the basic structure of the coding format. Also reviewed are several tips to help conquer the common hurdles to selecting a billable code — all aimed at increasing claims processing confidence and success.

What is the difference between ICD-10-PCS and ICD-10-CM?

Hodorowicz: ICD-10-PCS stands for the International Classification of Disease–10th Revision–Procedure Coding System. It is a system of medical classification used for procedural codes for medical interventions. Developed by CMS, it is for use in the United States for inpatient hospital settings only. ICD-10-CM stands for the International Classification of Diseases–10th Revision–Clinical Modification. The system is designed to classify and report diseases in health care settings; it does not contain a procedural code set.

Why did we change to the ICD-10 diagnosis coding system?

Susan Weiner

ICD-9-CM is 30 years old and no longer can support the needs of the 21st century health care system. Many diagnosis categories are full and, thus, cannot accommodate new codes, despite the fact that hundreds of new codes are submitted to the system annually. In addition, the codes are not descriptive enough; this makes it impossible to track, identify and analyze new clinical services and treatments available for patients. ICD-10 allows more codes, greater specificity and, thus, better epidemiological tracking. The new codes also will enhance accurate reimbursement for services rendered and facilitate evaluation of medical processes and outcomes so as to increase quality.

Who has to comply with ICD-10? Is CMS giving Medicare providers any flexibility or room for coding errors?

All HIPAA-covered entities must implement the new codes with dates of service or date of discharge for inpatients that occur on or after Oct. 1, 2015. While diagnosis coding to the highest level of specificity is the goal, CMS has given some providers some time flexibility with regard to this goal. For 12 months after ICD-10 implementation — meaning until Oct. 1 — Medicare review contractors will not deny physician or other practitioner claims for benefits paid under the Part B physician fee schedule (through automated medical review or complex medical record review) based solely on the specificity of the ICD-10 diagnosis code, as long as the Medicare physician or practitioner used a valid ICD-10 code from the right family of codes; the family code contain three characters, such as E11 (type 2 diabetes mellitus).

Mary Ann Hodorowicz

What code do I use if only signs or symptoms have been established, and not a definitive diagnosis?

As with ICD-9, ICD-10 codes are derived from documentation in the medical record. Therefore, if a diagnosis has not yet been established, the condition is coded to the highest degree of certainty, which may be a sign or symptom. In fact, ICD-10 contains many more codes for signs and symptoms than ICD-9 and is better designed for use in ambulatory encounters when definitive diagnoses are often not yet known. Nonspecific codes are also available in ICD-10 for use when more detailed clinical information is not known. Under ICD-10, encounters that do not treat a disease or injury are reported by a “Z” code in categories Z00-Z99. Example: Z00.00 is reported for an “encounter for general adult medical examination without abnormal findings”; Z00.01 is reported for an “encounter for general adult medical examination with abnormal findings.”

Will the hugely increased number of ICD-10 codes make it almost impossible for providers to code a claim correctly?

Actually, the greater number of codes in the ICD-10 system makes it easier to find a valid, billable code. This is because ICD-10 is much more specific and clinically accurate, and uses a more logical structure than ICD-9. But ICD-10 codes do have different rules regarding specificity, and most importantly, providers/suppliers are required to report code(s) with the highest degree of specificity based upon their clinical documentation in the medical record.

ICD-10 diagnoses are alphabetized in the Alphabetical Index. They are further defined in 21 chapters in the Tabular List, which also furnishes the specific instructional notes for identifying a valid, billable code. Each chapter begins with a capital letter, such as “E,” and groups together diagnoses of related etiology, signs or symptoms; for example, Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00-E89). The Tabular List is subdivided into category and subcategory codes from three to seven characters in length, with each character representing an element that adds more specificity to the diagnosis (see Figure).

Figure. Each character in category and subcategory codes represents an element that adds more specificity to the diagnosis. Image courtesy of Mary Ann Hodorowicz.

In reality, most practitioners work with a relatively small number of diagnosis codes related to a specific type of specialty in their practices. For example, endocrinologists and diabetes educators will typically report a subset of codes in Chapter 4: Endocrine, Nutritional and Metabolic Diseases.

The three character “category” or “family” codes below are generally not billable because codes with more specificity (more characters) exist. For example, code E10 (type 1 diabetes mellitus) is not billable. This code must have a fourth, fifth and sixth character after the decimal point to be billable.

Where can the Alphabetical Index and Tabular List of the ICD-10 codes be found?

In addition to the hard copy ICD-10-CM manual available for purchase online, there are also many Internet-based lookup and coding tools to help providers, billers and coders select a valid, billable code. My three favorite are these:

Always remember that the existence of a diagnosis or procedure code does not mean that the health plan will have a coverage policy for a particular service, such as diabetes self-management education.

Finally, the following ICD-10 diagnosis codes really do exist — in case you ever need them.

  • V97.33XD: Sucked into jet engine, subsequent encounter.
  • Y92.146: Swimming pool of prison as the place of occurrence of the external cause.
  • S10.87XA: Other superficial bite of other, specified part of neck, initial encounter.
  • W55.41XA: Bitten by pig, initial encounter.
  • Z63.1: Problems in relationship with in-laws.
  • W220.2XD: Walked into lamppost, subsequent encounter.
  • Y93.D: V91.07XD: Burn due to water skis on fire, subsequent encounter.
  • W55.29XA: Other contact with cow, subsequent encounter.

Disclosure: Hodorowicz and Weiner report no relevant financial disclosures.

In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with certified endocrine coder Mary Ann Hodorowicz, RDN, MBA, CDE, about the basic structure of the coding format. Also reviewed are several tips to help conquer the common hurdles to selecting a billable code — all aimed at increasing claims processing confidence and success.

What is the difference between ICD-10-PCS and ICD-10-CM?

Hodorowicz: ICD-10-PCS stands for the International Classification of Disease–10th Revision–Procedure Coding System. It is a system of medical classification used for procedural codes for medical interventions. Developed by CMS, it is for use in the United States for inpatient hospital settings only. ICD-10-CM stands for the International Classification of Diseases–10th Revision–Clinical Modification. The system is designed to classify and report diseases in health care settings; it does not contain a procedural code set.

Why did we change to the ICD-10 diagnosis coding system?

Susan Weiner

ICD-9-CM is 30 years old and no longer can support the needs of the 21st century health care system. Many diagnosis categories are full and, thus, cannot accommodate new codes, despite the fact that hundreds of new codes are submitted to the system annually. In addition, the codes are not descriptive enough; this makes it impossible to track, identify and analyze new clinical services and treatments available for patients. ICD-10 allows more codes, greater specificity and, thus, better epidemiological tracking. The new codes also will enhance accurate reimbursement for services rendered and facilitate evaluation of medical processes and outcomes so as to increase quality.

Who has to comply with ICD-10? Is CMS giving Medicare providers any flexibility or room for coding errors?

All HIPAA-covered entities must implement the new codes with dates of service or date of discharge for inpatients that occur on or after Oct. 1, 2015. While diagnosis coding to the highest level of specificity is the goal, CMS has given some providers some time flexibility with regard to this goal. For 12 months after ICD-10 implementation — meaning until Oct. 1 — Medicare review contractors will not deny physician or other practitioner claims for benefits paid under the Part B physician fee schedule (through automated medical review or complex medical record review) based solely on the specificity of the ICD-10 diagnosis code, as long as the Medicare physician or practitioner used a valid ICD-10 code from the right family of codes; the family code contain three characters, such as E11 (type 2 diabetes mellitus).

Mary Ann Hodorowicz

What code do I use if only signs or symptoms have been established, and not a definitive diagnosis?

As with ICD-9, ICD-10 codes are derived from documentation in the medical record. Therefore, if a diagnosis has not yet been established, the condition is coded to the highest degree of certainty, which may be a sign or symptom. In fact, ICD-10 contains many more codes for signs and symptoms than ICD-9 and is better designed for use in ambulatory encounters when definitive diagnoses are often not yet known. Nonspecific codes are also available in ICD-10 for use when more detailed clinical information is not known. Under ICD-10, encounters that do not treat a disease or injury are reported by a “Z” code in categories Z00-Z99. Example: Z00.00 is reported for an “encounter for general adult medical examination without abnormal findings”; Z00.01 is reported for an “encounter for general adult medical examination with abnormal findings.”

Will the hugely increased number of ICD-10 codes make it almost impossible for providers to code a claim correctly?

Actually, the greater number of codes in the ICD-10 system makes it easier to find a valid, billable code. This is because ICD-10 is much more specific and clinically accurate, and uses a more logical structure than ICD-9. But ICD-10 codes do have different rules regarding specificity, and most importantly, providers/suppliers are required to report code(s) with the highest degree of specificity based upon their clinical documentation in the medical record.

ICD-10 diagnoses are alphabetized in the Alphabetical Index. They are further defined in 21 chapters in the Tabular List, which also furnishes the specific instructional notes for identifying a valid, billable code. Each chapter begins with a capital letter, such as “E,” and groups together diagnoses of related etiology, signs or symptoms; for example, Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00-E89). The Tabular List is subdivided into category and subcategory codes from three to seven characters in length, with each character representing an element that adds more specificity to the diagnosis (see Figure).

Figure. Each character in category and subcategory codes represents an element that adds more specificity to the diagnosis. Image courtesy of Mary Ann Hodorowicz.

In reality, most practitioners work with a relatively small number of diagnosis codes related to a specific type of specialty in their practices. For example, endocrinologists and diabetes educators will typically report a subset of codes in Chapter 4: Endocrine, Nutritional and Metabolic Diseases.

The three character “category” or “family” codes below are generally not billable because codes with more specificity (more characters) exist. For example, code E10 (type 1 diabetes mellitus) is not billable. This code must have a fourth, fifth and sixth character after the decimal point to be billable.

Where can the Alphabetical Index and Tabular List of the ICD-10 codes be found?

In addition to the hard copy ICD-10-CM manual available for purchase online, there are also many Internet-based lookup and coding tools to help providers, billers and coders select a valid, billable code. My three favorite are these:

Always remember that the existence of a diagnosis or procedure code does not mean that the health plan will have a coverage policy for a particular service, such as diabetes self-management education.

Finally, the following ICD-10 diagnosis codes really do exist — in case you ever need them.

  • V97.33XD: Sucked into jet engine, subsequent encounter.
  • Y92.146: Swimming pool of prison as the place of occurrence of the external cause.
  • S10.87XA: Other superficial bite of other, specified part of neck, initial encounter.
  • W55.41XA: Bitten by pig, initial encounter.
  • Z63.1: Problems in relationship with in-laws.
  • W220.2XD: Walked into lamppost, subsequent encounter.
  • Y93.D: V91.07XD: Burn due to water skis on fire, subsequent encounter.
  • W55.29XA: Other contact with cow, subsequent encounter.

Disclosure: Hodorowicz and Weiner report no relevant financial disclosures.