Stakeholder Perspective on ICD-10 Preparation Coding Committee Meeting Paul Kinberg, DPM, Chair

Transcription

1 9312 Old Georgetown Road Bethesda, MD Tel: Fax: Stakeholder Perspective on ICD-10 Preparation Coding Committee Meeting Paul Kinberg, DPM, Chair ICD-10 Harry Goldsmith, DPM / David Freedman, DPM a. ICD-10 from the private insurance perspective Annie Boynton, BS, UnitedHealth Group (9am ET) b. ICD-10 from the Medicare perspective Fulfer / Patterson, Novitas (10am ET) c. ICD-10 from the CDC / CMS perspective Donna Pickett (12 noon ET) 1 Will you require laterality or will the edits accept the unspecified code? How will you handle bilateral conditions (require both the left and right codes or use an unspecified code)? Contingent on whether CMS adopts a position on this- United s bilateral policy is sourced to the NPFS. Future opportunity to tie the diagnosis codes to the modifier 50 or RT or LT is used to enforce correct coding principles. If there is a specific code or code(s) then specific codes should be used. Using a unspecified code, when a specified code is available, is not appropriate. Bilateral conditions will require the use of left and right codes. 1

2 2 Will you match up laterality in the ICD-10 diagnosis with the -RT / -LT CPT modifiers? What happens if those ICD-10 codes and CPT modifiers do not match-up? Use of the same diagnosis for different claim lines should not be an See above issue. 3 4 How will the computer edits handle the 7th digit alpha codes? Must change from A to D (for example) or if forget and continue to use A is that OK? Will the edits require a code for External Cause of Injury whether or not the accident/injury box is checked? 2 Still in process, majority of/largest systems (ICES, TOPS, and COSMOS) will want full 7 characters. May depend on what other diagnosis codes are reported. Today, we have no edits that require the reporting of an E codes (and ICES does not receive this field from TOPS to enforce any edit. This would probably The coding guidelines for A and D are specific. Physicians should remember to use A until active treatment of an illness/injury is complete. Once the issue has been resolved, use D. - E codes are not recognized for payment in in the claim payment systems. They are for use in trauma registries.

3 impact COB claims which do not pass through ICES today. 5 6 Will you require a cause (bacterial code) for infection? If so, will it be required on the initial visit (causing the claim to be held for the C&S results) or only on the follow-up exams? How particular will your edits be if the code sequences are out of the ICD-10 stated (required) order? 3 The only edit we have involves sequencing the diagnoses is a new policy that will be launched June 1, 2013, which will deny claims submitted with an inappropriate primary diagnosis. We ve already built in logic to consider this for ICD-10 codes in Today, the only edit that we have that involves sequencing the diagnosis is a new policy which will be launched on June 1, 2013 which will deny claims submitted with an inappropriate Use the most specific code known that is supported by the Medical Record. If the bacteria is unknown, code it to the unspecified agent. MCS (Part B) shops for diagnoses, so order is not an issue. In FISS (Part A) required sequencing is crucial.

4 primary diagnosis. We ve already built in logic to consider this ICD-9 codes in What will cause a claim to suspend to request additional information? 8 What will cause a claim to be denied? 9 Since pain in limb is an "M" code, will you require (recommend) that diagnosis be present (if there is pain as the reason for the visit) since it technically is not a symptom. Multiple issues, many are not related to diagnosis but to other issues with the claim. Multiple issues. Many are not related to diagnosis but to other issues within the other claim. No final decision has been made yet. An LCD is present requiring additional information, MR is doing review or errors are made in other areas of the claim. An LCD is present and medical necessity is not met, MR has done a review and medical necessity is not met or errors are made in other areas of the claim. If you know the reason for the pain, use it as the diagnosis. If you do not then use the M code. 4

5 10 If the patient has a suspected neoplasm but are doing a biopsy to determine the underlying cause can you use the equivalent of the diagnosis ICD or D49.2? Yes, mapping is equivalent from to D49.2, all other things being equal. Remember a suspected diagnosis is for inpatient use only. It No final decision yet- still in review with Oncology policy group. cannot be used in the outpatient setting. Should consider Mass by site until they know from the biopsy. 11 Signs and symptoms associated with neoplasms listed in Chapter 18 according to guidelines are not to be listed as principal or first listed diagnosis codes with that be so with private carriers? We will likely follow CMS and coding regulations on thisbut no final decision on this has been made yet. MCS (Part B) shops for diagnoses, so order is not an issue Page 28 of the coding guidelines should be should be reviewed to identify when the neoplasm should be coded if being treated. 5

6 A podiatrist should assign the correct diabetes code that is the reason for the patient s visit. If the patient has severe PVD and is diabetic I would think the practitioner would inquire as to the type of diabetes or what medication 12 including insulin the As podiatrists and assigning diabetes codes, default minimum is E11 Type 2 patient is taking. diabetes per guidelines, are we expected to code a patient using insulin Z79.4, That is good medical even though we are not prescribing their insulin? practice. If the patient is being seen due to a vascular foot issue or a neuropathy issue they would use the specific complication code such as E11.40 type 2 diabetes with diabetic neuropathy. If seen for an ingrown nail, 6

7 then code first the diabetes, then L60.0 for ingrown nail. We would expect coding guidelines to be followed here If the patient has a personal history of a pressure ulcer, the guidelines say that if the ulcer is completely healed do not assign a pressure ulcer code? The guidelines say cellulitis of the foot is classified to cellulitis of the lower limb 7 This is correct. ICD- 10 has codes for cellulitis of the finger and toe. That is correct, ICD- 10 also has codes for cellutis of the finger and toe. Healed ulcer = personal history of ulcer which should be coded if such a code is available. Ulcers are coded to Stages 1-IV (L896.--) and the right and/or left code for laterality must also be coded. If it is a stage 0 then code to unstageable. Cellulitis of the foot codes to ICD-9 diagnosis code (except toe). ICD-10 diagnosis codes are L026. L031. Again coding of right or left laterality is

8 required When a patient has dermatitis/eczema current ICD9 code is 692.9, in ICD 10 L23.9, L24.9 and L25.9 are the mapped codes but they are unspecified codes will using these codes effect the reimbursement? Guidelines for an injury says the A add on code may be used on more than one claim for the same patient as this may happen in a emergency room, will the plan allow that after the ED physician has seen the patient and the consulted physician would be expected to use the same diagnosis code with the A as last add on code? 8 The assumption would be the physician would be treating the patient during the entire initial stay, so would use the appropriate diagnosis. As the patient is not returning for a subsequent encounter during the same stay, it would follow that the diagnosis would have an A if this is the appropriate qualifier for the diagnosis. The assumption would be the physician would be treating the patient during the entire initial stay, so would use the appropriate Need to review for the presence of a converted LCD for necessary diagnoses. Remember, timing of publication of these decisions (converted LCDs) has not yet been made (formal expectation (e.g., for MCD) is March or later)) but there will be time to allow for comments and feedback. MCS does not look back in this way Medicare will allow the same code, but its use is not required.

9 diagnosis. As the patient is not returning for a subsequent encounter during the same stay. It would follow that the diagnosis would have an A if this is the appropriate qualifier for the diagnosis According to guidelines, the A is also needed for the entire hospital stay -- will that be expected? A fracture not indicated as open or closed will be coded as closed, but a fracture not indicated as displaced or nondisplaced is coded as displaced, will you follow this rule? As long as the patient is in a continuous stay- Yes It is up to the physician to diagnose and submit the appropriate ICD-9 and ICD-10 code. No difference from today. A is to be used as long as the patient is receiving active treatment, so the answer is yes. Please see page 49 of the guidelines. You will need to follow the coding rules for the answer, unless there is a LCD that describes nuances to this. Use the LCD in this situation. 9

10 If a patient is x-rayed and there is the presumption of osteoporosis, the You will need to follow the coding rules for the 19 guidelines say if there is known osteoporosis, do not use traumatic fracture answer, unless code but code to M80 Osteoporosis with current pathological fracture, will there is a LCD that this be so? describes nuances to this. Use the LCD in this situation. Notes: ICD-10 talk with Annie Boynton, United: Software- How well are they on track? Checks and balance? (Dr. Freedman) Annie: Communication- Data Service: Rick Horsman: Big volume is going to come from not the best - Publish the findings on the ICD page and also the United s bulletin. Debra Patterson, Novitas There are approx. 330 NCDs, spanning a range of vintages, but not all are appropriate for translation. LCD Conversion Steps: 1) Cross-walk all ICD-9 codes to ICD-10 codes 2) Determine if LCD is still effective (consider retirement) 3) Refine ICD-10 codes in LCDs that will be kept to take advantage of additional specificity Accomplish system testing (MCS & FISS). Currently planned for later in 2013 when instructed by CMS. Same code to represent bunion- specific code would be great. 10

11 Planning on implementing provider education- not confirmed date. November CAC would be a good time to start the discussion with other organizations (like us) Send issues to discuss at the meetings: Contractors set to meet once a month. A: initial encounter D: Subsequent encounter S: Sequelae Dr. Freedman: Which will be the most specific primary diagnosis code? It will be L Essential for every LCD that governs your work- could be one Software being used at Novitas, also being used nationally? The way system operates is national. Dealing with co-morbidity- are we supposed to code with that specificity (detailed)? As long as you have the requestion (7 digit) number then it will go in and as long as you have the higher level specificity code- it should get paid. Coding right or left laterality is required. Need to review for the presence of a converted LCD for necessary diagnoses. Novitas has an ICD-10 section CDC: Whether there will be another delay in ICD-10 implementation- Aprox programs that will be impacted by this-focusing on their program to be ready for the ICD-10 switchover Electronic Data Exchange conducted a survey in March- Summary- Survey results are broken up: vendor, health providers, and health plans. Working with specialty groups, CDC is developing educational materials. Includes specific information about the particular specialty coding. David Freedman- Is there an inventory with all the requests that APMA made? CDC is working on that- follow-up with you in June. Follow-up meeting on this with folks from the Coding Committee. Original final rule allows for dual reportage. How do we go forward with the contingency plan? (Dr. Santi)- Coding Committee proposed recommendations: 1) Request a transitional period for ICD-9/10 to 6-12 months 2) Drop the 6 and 7 characters from ICD-10 3) Eliminate penalties from erx, meaningful use, PQRS 11

12 Should we also approach individual specialties? State Associations should get involved. Focus on educating the coders/billers, medical assistants. Dr. Aung Create an ICD-10 module -Appeal to different age groups/personalities Coding Seminars Proposals: All speakers compensated and States cover speakers cost. 1) Weekend vs. Midweek- Premium for midweek 2) APMA Staff makes best reasonable financial decision in terms of speakers 3) State may suggest speaker but does not have final say Stand-alone for profit- Revenue sharing Coding Resource Center: When should we put the ICD-10 tab? Conversion ICD-9 to ICD-10? For the Coding Committee, we can get them a link to the dvlp site! Increasing prices in August. 12