ICD Months In Are You Doing it Right?

Transcription

1 ICD Months In Are You Doing it Right? Presented by: Kathy Mills Chang, MCS-P, CCPC What Now? Most commonly asked questions Based on hundreds of questions to the Help Desk and at seminars Proactively manage your billing Know how to appeal Plenty of time for Q&A at the end to cover your stumbling blocks #1 Audit Your Claims--Proactively What Could Go Wrong? Claim rejections from the clearing house Claim rejections between clearing house and carrier Claim rejections by the carrier Denials from the carrier Post payment audit denials Make Sure Your Codes Are Permissible Have You Programed Your Qualifiers? (855)

2 Paper Claims: 9 for ICD-9; 0 for ICD-10 Not to Be Confused With 431 = Onset of Current Symptoms or Illness Did You Use the 7 th Digit Appropriately? Why the 7 th Digit? Most categories in chapter 19 have seventh character extensions A, Initial encounter A D or S D, Subsequent encounter S, Sequela A vs. D What s an Encounter? (855)

3 Was There an Excludes 1 Note You Missed? Excludes 1 A type 1 Excludes note is a pure excludes note. It means "NOT CODED HERE! An Excludes 1 note indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note. An Excludes 1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Excludes 2 A type 2 Excludes note represents "Not included here". An Excludes 2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes 2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. Radiculitis NOS vs. With Radiculopathy Radiculitis (M54.1-)is included with M50.1 or M51.1 disc disorder with radiculopathy series The Excludes notes are clear! Lumbar radiculopathy (M54.16) could be used if the pain is not known to be a disc yet but it does radiate from the lumbar spine Could also be Sciatica (M54.3-) w/o disc confirmation and radiation down the back of the leg Resist the Urge! Do not code symptom codes like cervicalgia and lumbago with disc codes Symptoms are included within the more definitive DX codes of the more complicated condition #2 Spot Check Your Documentation Good Documentation Tells a Story (855)

4 Review Every Aspect of the DX Pull a random chart Identify the DX Check coding book: Is this the highest degree of specificity? Review the history and exam documentation Do you know what SHOULD be there based on the DX? Review Every Aspect of the DX If appropriate, does the site specific DX match the complaint? Is the Diagnostic Impression obvious? Has the assessment been updated since October 1? Is there a mechanism of injury? Did you use an external cause DX code? Example: Sprain vs Strain Sprain and strain codes have been separated in ICD-10 DCs tend to clump them together Sprain codes must represent pain on passive ROM Strain codes must represent pain on active ROM OK to use both when the documentation demonstrates both Tests demonstrate tendons vs. ligaments M50 series: Cervical Disc Disorders M51 series: Thoracic, Thoracolumbar, and Lumbosacral IVD Disorders Example: Disc Disorders 4 th Characters 0 = disc disorder with myelopathy 1=disc disorder with radiculopathy 2=other disc displacement 3=other disc degeneration 4= Schmorl s Nodes (not cervical) 8=other disc disorders 9=unspecified disc disorder Example: Disc Disorders What s a Disc Disorder? Protrusion Bulge Herniation These are appropriate when using 4 th character 0 or 1 Disc Displacement-4 th character 2 may include these also However, doesn t include cord or nerve root complications M40.12: Other secondary kyphosis, cervical M40.292: Other kyphosis, cervical region Example: Cervical Kyphosis Choose 1: Patient had an incident that resulted in cervical kyphosis Choose 2: Acquired kyphosis with no evidence or knowledge of another condition that may have prompted it (855)

5 Example: Restricted Motion Stiffness or restricted motion is included in the segmental dysfunction codes for the spine Segmental dysfunction can include reduced or restricted ROM M25.6 = Stiffness in joint, NEC These are for extremities Example: Contracture vs. Spasm M62.49 (Contracture of Muscle multiple sites) Muscle contracture is a more severe condition with actual tightening and stiffening of a muscle More long lasting, more difficult to heal Reoccurs periodically Difficult to manage M (Muscle Spasm of the Back) More likely what is revealed in documentation findings More intermittent and more likely to come and go More easily managed #3 Appeal if Rejected Why Appeal? Not appealing looks like you are haphazardly billing Appealing improves the practice s bottom line Improves communication between providers and insurance companies Defends your services Lack of Medical Necessity Does your documentation tell a believable clinical story that makes sense as to why you are still treating and why you should get paid? It is Simple and Straight Forward When the problem is an administrative issue, the solution is fairly straight forward. Review the remark codes or concerns Determine if their concern is valid (855)

6 Unsupported Code Denials What has the patient agreed to with their Insurance Policy? What have you agreed to with your Provider Contract? What does the Medical Review Policy say? Know the fine print! Unsupported Codes The contract agreement can tie our hands regarding covered treatment options. Know your contract & the Medical Review policies Use the ACA policy statements to argue your case For the insurance companies you frequently deal with, or are a Provider for KNOW THEIR RULES! Create a short list of non-covered codes or what they define as experimental codes Know the Territory Lack of Medical Necessity Denials Does your documentation tell a believable clinical story that makes sense as to why you are still treating and why you should get paid? Basically, functional improvement is noted, and not completely resolved yet Medical Necessity Appeal Medical Necessity is supported by documentation that shows: a functional deficit, the patient is responding to treatment, yet full recovery of the functional loss hasn t been achieved. The patient s ICD-10 diagnosis of their condition is demonstrated by objective findings An appropriate Treatment Plan with functional Treatment Goals are determined and documented. Medical Necessity Appeal (855)

7 Beginning the Appeals Process Use the information found on the EOB to ensure you are aware of any time restrictions for your appeals process Send timely appeals, or risk denial When following up Ask to speak to a supervisor within the insurance company Talk to Provider Relations to get training about specifics of your Provider Contract and billing requirements Continued Denials Continued Denials Use your resources for additional assistance State Chiropractic Association American Chiropractic Association Get your State Department of Insurance or Insurance Commissioner involved Most Commonly Asked Q s Changing DX Q: Do I have to change the DX every time the patient is seen, even if they are seen 3X per week? A: No, no, and oh my goodness NO! Well, maybe. Huh? Q: Which subluxation codes should DCs be using for major medical claims? A: Why are you using subluxation codes for major medical claims? A: M99.0X series is approved for Medicare A: S13.101_ ; S23.101_; S33.101_series = Dislocation Be Sure! Subluxation Codes (855)

8 How Do I Point DX Codes? Q: The software will only allow for pointing of up to 4 DX codes. How do I point to 6 codes if billing a 98941? A: Only 4 codes can point to each charge. It s not necessary to point when is being billed. Coding Anatomical Short Leg Q: I have used ICD-9 codes with as my go to pelvic region diagnosis. the new icd10 equivalent to seems to be a true short leg which is not what I'm trying to convey. I've done the mapping tool and can t find a similar code and am clueless on musculoskeletal code(s) for the pelvic region. Help! A: There is not a way to code specifically for the short leg unless it is an actual short leg as you have described below. You would code for the appropriate segmental dysfunction (M99.0x) and document the short leg finding. The other alternative for you is to consider R29.3 for abnormal posture and note this due to unequal leg length. (855)