ICD-10-PCS adds new codes for 2014

The ICD-10-PCS codes for 2014 are now available on the CMS website. CMS also posted the 2014 ICD-10-PCS guidelines and an ICD-10-PCS reference manual.

You will find four new codes under new technology application, valid October 1, 2013

• 08H005Z, insertion of epiretinal visual prosthesis into right eye, open approach
• 08H105Z, insertion of epiretinal visual prosthesis into left eye, open approach
• 30280B1, transfusion of nonautologous  4-factor prothrombin complex concentrate into vein, open approach
• 30283B1, transfusion of nonautologous  4-factor prothrombin complex concentrate into vein, percutaneous approach

The update also includes three new codes added and three codes deleted, to correct body part value for temporary  occlusion of abdominal aorta.

The new codes are:

• 04V00DJ , restriction of abdominal aorta with intraluminal device, temporary, open approach
• 04V03DJ, restriction of abdominal aorta with intraluminal device, temporary, percutaneous approach
• 04V04DJ
• restriction of abdominal aorta with intraluminal device, temporary, percutaneous endoscopic approach

These three codes were deleted:

• 02VW0DJ, restriction of thoracic aorta with intraluminal device, temporary, open approach
• 02VW3DJ,  restriction of thoracic aorta with intraluminal device, temporary, percutaneous approach
• 02VW4DJ, restriction of thoracic aorta with intraluminal device, temporary, percutaneous endoscopic approach

In addition, the section title for the Radiation Oncology section was revised to Radiation Therapy. No code titles were changed.

AMA acknowledges problems with skipping ICD-10

The American Medical Association (AMA) may not push for CMS to move directly to ICD-11 without implementing ICD-10 after all, according to a report of the AMA’s Board of Trustees. The report will be submitted to the House of Delegates during its June meeting and until approved by the delegates, it does not represent the AMA’s official position.

AMA members discussed potentially advocating for ICD-11 over ICD-10 during the AMA’s 2012 annual meeting. During that meeting, the AMA House of Delegates adopted Policy D-70.952 “Stop the Implementation of ICD-10.” The policy called for investigating the benefits of moving from ICD-9 to ICD-11.

It turns out that skipping ICD-10 may not be a good thing. The report to the board lists only three reasons to move directly to ICD-11:

• ICD-11 implementation would be costly and time-consuming regardless of whether the US implements ICD-10
• Physicians would only have to go through one transition, not two
• By waiting for ICD-11, healthcare organizations will have more time to adopt electronic medical records develop the electronic systems infrastructure for health information exchange

The AMA report lists six reasons not to wait for ICD-11 including:

• ICD-9 is outdated and limited (thanks for finally noticing)
• Healthcare will miss out on the improvements associated with ICD-10 coding, such as laterality, greater specificity, and more room to add codes
• Healthcare providers and coders will have a more difficult time learning ICD-11 without learning ICD-10 first
• Focusing solely on moving from ICD-9 to ICD-11 risks missing the opportunity to educate physicians and leaving them unprepared for the anticipated transition to ICD-10, which could result in significant cash flow disruptions
• ICD-10 should reduce payers’ requests for additional information, which eases the burden on physicians
• ICD-11 is still 20 years away from implementation (the World Health Organization is still working on the codes and ICD-11 won’t even be beta tested for another two or three years)

That does not mean that the AMA now endorses ICD-10 implementation. It doesn’t.  The AMA touts its success in holding off ICD-10 implementation for more than a decade and for convincing HHS to push the date back from October 1, 2013, to October 1, 2014.

The AMA “harbors serious concerns and reservations” about the burden of ICD-10 implementation and based on current information, doesn’t not recommend moving from ICD-9 straight to ICD-11.

I think it’s great that the AMA is finally acknowledging some of the benefits of ICD-10, but I wish the AMA would actually endorse the switch. Change is never easy, but we’ve put this off long enough.

ICD-10 itself is getting a little long in the tooth. The World Health Organization released the first version of ICD-10 in 1998. Twenty-five countries already use ICD-10, although most don’t use it for reimbursement purposes like the US will.

The benefits to implementing ICD-10 outweigh the disadvantages and frankly, we can’t keep using ICD-9.

Healthcare organizations on both the provider and payer sides have already spent considerable time and money preparing for the transition. Better technology and better patient information are good things. I just wish the AMA would see it that way.

MS-DRG shifts in ICD-10-PCS

In a perfect world, inpatient facilities would receive the same payments for diseases and procedures after the switch to ICD-10-PCS. We know that won’t happen, that facilities will see some shift in MS-DRG assignment and as a result, different reimbursement.

Why will certain conditions track to different MS-DRGs? In part, code assignment to MS-DRGs will change because the coding guidelines are changing. Specificity is increasing in many cases and decreasing in a few.

ICD-10-CM also changes the meaning of some of the diagnosis descriptions by including more combination codes and is also changing the CC/MCC designations for some codes.

Don’t forget about coding errors. Coders may be incorrectly assigning an ICD-9-CM code now, which could lead to incorrect MS-DRG assignment. In ICD-10-PCS, coders may also assign an incorrect code by choosing the wrong root operation. That could also lead to a change in the MS-DRG.

Hospitals should begin looking at their top MS-DRGs and determining whether the documentation is sufficient to code in ICD-10. Then code the case in ICD-10 and see which MS-DRG it ends up in. Is it the same MS-DRG, a higher paying MS-DRG, or a lower paying one?

Then try and determine why the MS-DRG changed. Maybe you have more specific information. You could be picking up a CC or MCC you aren’t currently reporting. Are you correctly sequencing the codes?

Once you figure out what will happen with your top MS-DRGs, you’ll have a better understanding of the financial impact of ICD-10 and also have a starting point for physician education.

Change your EMR to prepare for ICD-10

Do you want to work harder or work smarter? We all know electronic medical records (EMR) are great in some ways, not so great in others. Drop down menus make life easier for physicians, but can also result in physicians choosing the first version of a disease on the list. And that’s usually the most non-specific version of the disease.

EMRs can help improve documentation for ICD-10-CM if you add the correct prompts.

Consider fracture codes. In ICD-10-CM, coders will need more detailed information in order to assign a fracture code, including:

• Specific site (which bone and where on the bone)
• Side (left or right)
• Type of fracture (open or closed, displaced or non-displaced)
• Encounter (initial, subsequent, sequela)

Why not prompt the physician to include that information? Consider adding a drop down for site of the fracture, the encounter, and the type of fracture. Make it easy for the physicians to give coders the information they need.

To assign a code for percutaneous transluminal coronary angioplasty (PTCA), coders need to know the device so add a drop down with these choices:

• Intraluminal Device, Drug-eluting
• Intraluminal Device
• Intraluminal Device, Radioactive
• No Device

Coders need additional information for pregnancy, both trimester and weeks of gestation. Add a drop down so the physician must include that information.

Avoid giving the physicians an easy out in the drop down menus. You want them to be as specific as possible, so force them to be specific.The more information coders have, the fewer queries they’ll need to make. And that saves everyone time.

Remember too that physicians may already be documenting some of this information. Coders just aren’t looking for it. So before you reinvent your EMR, make sure you know which changes will be beneficial.

Don’t burn those ICD-9-CM Manuals just yet

Planning a big bonfire for October 1, 2014, using your ICD-9-CM Manuals? You might want to think again.

Not everyone is required to transition to ICD-10. Only HIPAA covered entities must begin using the ICD-10 code sets. Non-covered entities, such as can workers’ compensation and auto insurance carriers, still use ICD-9 if they choose.

As a result, we may be using ICD-9-CM forever. Or maybe just for a little while. Each non-covered entity will make its own decision on when or if to switch to ICD-10-CM. I wouldn’t be surprised if many of them wait a year (I know, not what you wanted to hear). I think eventually they will start using ICD-10-CM, hopefully before the transition to ICD-11, whenever that comes around.

In the meantime, talk with any workers’ compensation or auto insurance carriers you do business with and find out whether those plans will be moving to ICD-10. If not, you need to determine whether to keep a dual-coding system in place or not accept patients from those carriers.

Use ICD-10 to tell a better story about the patient

I love the ICD-10-CM external causes codes. I’m weird, I know, but I’m also a writer and I love telling good stories. When I first started coding, my boot camp instructor Peggy Blue, MPH, CPC, CCS-P, said coders tell the patient’s story using codes. ICD-10-CM allows coders to tell better stories about patients and detail what happened to them and how.

Some of the external causes codes are pretty funny and you’ll probably never report them. If you work in an urban setting, you’ll probably never report W61.4- (contact with turkey) unless someone is trying to kill his or her own Thanksgiving dinner.

If you don’t live near water, you likely won’t need V94.1 (bather struck by watercraft) or W56.2- (contact with orca). Well, you might need the orca, dolphin (W56.0-), and sea lion codes (W56.1-) if you work near Sea World. But let’s hope you don’t have cause to use them.

The ICD-10-CM external causes codes include codes for encounters with a variety of animals including, but not limited to:

• Alligator
• Crocodile
• Nonvenomous reptiles
• Parrot
• Macaw
• Chicken
• Goose
• Frogs
• Toads
• Squirrel
• Cow
• Dog
• Cat
• Mouse

The only thing missing seems to be an attacking partridge in a pear tree. Oh wait, that’s contact with other birds (W61.9-).

Those codes seem to get the most attention. In fact, Rep. Ted Poe, R-Texas, called out the turkey codes as a way to bolster his argument that the government should stop ICD-10 implementation. He’s even introduced a bill—H.R. 1701: Cutting Costly Codes Act of 2013—to that effect. Take two minutes and read the bill. Trust me, you’ll only need two minutes. It’s not very long.

Poe also mocked the codes for walking into a lamp post (W22.02-). I’ve made fun of that code too, mainly because I can’t image anyone actually admitting he or she walked into a lamp post. At least not sober.

Here’s something he didn’t consider though. How often does an abuse victim claim to have walked into a door or fallen down the stairs? So if a physician or nurse sees a patient who is always walking into things, the clinician might suspect abuse. Or that the patient has a problem with vision. That can be valuable information when forming a diagnosis and also to potentially support a criminal charge against an abuser. Or a bully.

We know ICD-10 will change the way we code. We know it’s going to cost a lot of money and decrease productivity. But we also know (at least I hope we do) that ICD-10 will give us better data and a better clinical picture of the patient’s condition. That alone is a good reason to move forward with implementation.

Here are four other good reasons:

• ICD-9 is out of space
• We’ve already spent literally millions preparing for the change
• We can’t talk to the rest of the world about healthcare, diseases, and mortality rates
• We’re 15 years behind Canada

On a more serious note, we all hope we never have to use any of the codes under Y36.5 (war operations involving nuclear weapons).

Get to know ICD-10 codes for wrist and hand conditions

Penny comes in to see Dr. Morang for pain in her wrist. After performing a comprehensive exam and history, Dr. Morang documents the following ICD-9-CM codes:

• 354.0, carpal tunnel
• 715.04, osteoarthrosis, generalized, hand
• 719.43, pain in forearm
• 728.6, contracture of palmer fascia

How would we code Penny’s diagnoses in ICD-10-CM? Let’s start with her carpal tunnel. If we look up syndrome, carpal tunnel in the ICD-10-CM Alphabetic Index, it directs us to G56.0-. The dash tells us the code needs additional characters, so we absolutely must look in the Tabular Index.

You should never code from the Alphabetic Index alone, anyway. That’s one of the many things that won’t change after the transition to ICD-10-CM.

G56.0 gives us three choices:

• G56.00, carpal tunnel syndrome, unspecified upper limb
• G56.01, carpal tunnel syndrome, right upper limb
• G56.02, carpal tunnel syndrome, left upper limb

We need to review Dr. Morang’s documentation to determine the laterality so we can assign the most detailed code. ICD-10-CM does include an unspecified option, but we want to avoid reporting unspecified if at all possible. That means if the physician didn’t document laterality, query!

Moving on to the osteoarthrosis, we find a note in the Alphabetic Index that tells us to see also Osteoarthritis.

Generalized osteoarthrosis of the hand doesn’t really give us much to go on to find the correct ICD-10-CM code. We need more information.

Does Penny suffer from bony bumps on the finger joint closest to the fingernail (Heberden’s nodes), which would lead us to ICD-10-CM code M15.1 (Heberden’s nodes [with arthropathy]).

Or does she have bony bumps on the middle joint of the finger (Bouchard’s nodes)? In that case, we would report M15.2 (Bouchard’s nodes [with arthropathy]).

Does Dr. Morang mean Penny suffers from osteoarthritis of the hand joint or the bones in her hand in general?

We also need to know if the osteoarthrosis is primary, secondary, or post-traumatic.

For the pain in Penny’s forearm, we again need laterality. Our choices are:

• M79.631, pain in right forearm
• M79.632, pain in left forearm
• M79.639, pain in unspecified forearm

We also need to know if the pain is a separate problem or if it is a symptom of one of Penny’s other diagnoses. If it’s a symptom, we don’t code it separately (regardless of what Dr. Morang says).

Finally, we need to code the contracture of palmer fascia. You may be more familiar with the term Dupuytren’s contracture. Both lead us to the same ICD-10-CM code—M72.0 (palmar fascial fibromatosis [Dupuytren]).

Interestingly, M72.0 does not require laterality. We only have one code, which could be a problem if Penny develops the same condition in both hands.

So we’ll wish Penny well, but avoid shaking her hand.

ICD-10-PCS body system, body part: They both sound so simple!

When coders begin using ICD-10-PCS the second and fourth character definitions seem simple enough:

• Second character-Body system
• Fourth character-Body part

However, when coders start assigning codes, they will need to note these things from the ICD-10-PCS General Body Part Rules :

•  The body systems and body parts are specific to ICD-10-PCS and do not represent those typically found in an anatomy.  So don’t expect them to line up perfectly with your anatomy and physiology training. The good news is that they do conform entirely to the body systems and body parts found in ICD-10-CM chapters.
• The body system designations subdivide into smaller components. This makes sense as the ICD-10-PCS system is highly specific. For example, the genitourinary system subdivides into the urinary system, female reproductive system and male reproductive system.
• Sometimes a procedure is performed on a general anatomical region rather than a specific body system. For example a postoperative bleed into the peritoneal cavity is coded to Anatomical region: general and the body part peritoneal cavity.
• The body part designations also are specific to ICD-10-PCS and do not represent body parts as describe in anatomy books.  Example: The liver is one organ but ICD-10-PCS includes three possible body part designations : right lobe, left lobe, and liver.
• ICD-10-PCS also includes “general body part designations” which are considered not otherwise specified codes or NOS.  These designations should only be used when the documentation does not support assignment of a more specific code. For example, liver should be assigned only when the documentation in the medical record does not indicate the part of the liver and the coder cannot obtain the information from the physician.  This could potentially mean a physician query to assign the most specific body part designation.
• When the documentation describes a portion of a body part and ICD-10-PCS does not have a specific designation for that part then the whole body part designation is used. For example, if a procedure is performed on the alveolar process of the mandible the character for mandible is assigned because the alveolar process is not specifically identified as a separate body part.
• Body parts with the prefix “peri” (which means around or surrounding) may have a specific character for the body part. If not report the body part preceded by the prefix “peri” in the operative report with the character for that body part. Example: Pericardium is designated as a specific body part. However, “perirenal” does not have a specific body part and would assigned to the body part renal.

To use ICD-10-PCS effectively and efficiently, coders will need to learn the ICD-10-PCS Body Part Rules for four body systems:

• Cardiovascular
• Nervous
• Musculoskeletal
• Integumentary

Small practice readiness concerns CMS’ Buenning

You know what keeps you up at night thinking about the ICD-10 transition. Have you ever wondered what causes CMS officials to lose sleep?

For Denise Buenning, MsM, director of CMS’s administrative simplification group in the office of E-health standards and service, it’s the concern that small practices will not be ready to move to ICD-10. Buenning shared her concern with the audience at the AHIMA ICD-10-CM/PCS and CAC Summit in Baltimore April 24.

Large hospitals and systems have the resources and the awareness to be ready to go live October 1, 2014. However, small practices, those with one or two physicians, may not even be aware of ICD-10 because it’s not a priority for them. They are worried about seeing patients and keeping the doors open.

If they don’t transition to ICD-10, they won’t get paid. CMS is taking a number of steps, including “putting boots on the ground” in rural areas, to help small providers navigate the change, Buenning said.

CMS is considering a number of risk mitigation plans if small providers are not ready October 1, 2014, Buenning said.

“We are looking at everything except moving the implementation date,” as part of the risk mitigation, she added.

CMS recommits to October 1, 2014 implementation

It was almost inevitable. The possibility of another ICD-10 delay was brought up during the AHIMA ICD-10-CM/PCS and CAC Summit in Baltimore April 24.

And just as quickly as it was raised, the possibility was shot down by Denise Buenning, MsM, director of CMS’s administrative simplification group in the office of E-health standards and service.

“I have absolutely no reason to believe that the ICD-10 deadline will move again,” Buenning said.

Healthcare organizations have spent literally billions of dollars preparing for the ICD-10 conversion, Buenning said. In addition, CMS recognizes the benefits ICD-10 will bring to the ehealth ecosystem.

Buenning said it would be “problematic not to implement ICD-10” and added that CMS is absolutely dedicated to go-live on October 1, 2014.