of 19 /19
www.prsnetwork.com 12301 Grant Street, Thornton, CO 80241  |  Phone: (800) 9729298  |  Fax: (303) 5340577 Coding: ICD10 and Common Coding Questions Mark N. Painter www.prsnetwork.com 12301 Grant Street, Thornton, CO 80241  |  Phone: (800) 9729298  |  Fax: (303) 5340577 Objectives Successfully adapt current coding and documenation practices to the New ICD10CM system Properly bill incident toencounters Determine coding for the appropriate level of MDM for evaluation and management services 

Coding: ICD 10 and Common Coding Questions

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Microsoft PowerPoint - Mark Painter [Compatibility Mode]Coding: ICD10 and Common  Coding Questions
Mark N. Painter 
Objectives
• Successfully adapt current coding and documenation  practices to the New ICD10 CM system
• Properly bill “incident to” encounters 
• Determine coding for the appropriate level of MDM  for evaluation and management services 
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ICD10 Preparation
• Check with vendor preparations
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ICD9CM vs ICD10CM Overview ICD9CM Diagnosis Codes ICD10CM Diagnosis Codes
Approximately 14,000 codes  Approximately 69,000 codes
35 characters in length 4 – 7 characters in length
First digit may be alpha (E or V) or  numeric. Digits 2 – 5 are numeric
Digit 1 is alpha; digit 2 and 3 are  numeric; digit 4 – 7 are alpha 
Limited space for new codes Flexible for adding new codes
Lacks detail Very specific
Lacks laterality Has laterality
No placeholder Characters Has a placeholder character – character “X” used as 5th and 6th
character placeholder to allow for  expansion
Procedure (PCS) Codes: ICD-9 - 3,824 codes ICD-10 - 72,589 codes
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Considerations
– Will there be changes to your templates
– Can you run both systems now?
– Will you need to learn new search features
– Develop a backup system for the first few weeks  of ICD10, there will be glitches.
– Get training if you need it (book training now,  cancel later if you do not need it)
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ICD 10 Format and Structure
Overall similar to ICD9CM • Alphabetic Index
– Index of disease and injury – Index of External Causes of Injury – Table of Neoplasms – Table of Drugs and Chemicals Organized by main term describing the disease and/or condition
• Tabular list  – Body System – Condition Organized by chapters based on body system or condition – similar 
but differences
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ICD10CM TABULAR LIST of DISEASES and INJURIES  Table of Contents
1 Certain infectious and parasitic diseases (A00B99) 
2 Neoplasms (C00D49) 
3 Diseases of the blood and bloodforming organs and certain disorders involving the immune mechanism (D50 D89) 
4 Endocrine, nutritional and metabolic diseases (E00E89) 
5 Mental and behavioral disorders (F01F99)
6 Diseases of the nervous system (G00G99)
7 Diseases of the eye and adnexa (H00H59)
8 Diseases of the ear and mastoid process (H60H95)
9 Diseases of the circulatory system (I00I99)
10 Diseases of the respiratory system (J00J99)
11 Diseases of the digestive system (K00K94)
12 Diseases of the skin and subcutaneous tissue (L00L99)
13 Diseases of the musculoskeletal system and connective tissue (M00M99)
14 Diseases of the genitourinary system (N00N99)
15 Pregnancy, childbirth and the puerperium (O00O99)
16 Certain conditions originating in the perinatal period (P00P96)
17 Congenital malformations, deformations and chromosomal abnormalities (Q00Q99)
18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00R99)
19 Injury, poisoning and certain other consequences of external causes (S00T88)
20 External causes of morbidity (V00Y99)
21 Factors influencing health status and contact with health services (Z00Z99)
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XX
Added code extensions (7th
injury
Additional Characters
3 – 7 Characters
• Urolithiasis (N20N23)
that with hydronephrosis (N13.2) 
• N20.0  Calculus of kidney  – Nephrolithiasis NOS Renal calculus Renal stone Staghorn  calculus Stone in kidney 
• N20.1  Calculus of ureter  – Ureteric stone 
• N20.2  Calculus of kidney with calculus of ureter  • N20.9 Urinary calculus, unspecified 
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Top Dx Cross Walk
N13.2 Hydronephrosis with renal and ureteral calculous  obstruction
N13.30 Unspecified hydronephrosis
N13.39 Other hydronephrosis
236.91 Renal Mass N28.89 Other Specified Disorders of the Kidney and Ureter
592.0 Calculus of Kidney N20.0 Calculus of kidney
N20.2 Calculus of kidney with calculus of ureter
592.1 Calculus of Ureter N20.1 Calculus of Ureter
189.0 Renal Cancer C64.1 Malignant neoplasm of right kidney, except renal pelvis
C64.2 Malignant neoplasm of left kidney, except renal pelvis
C64.9 Malignant neoplasm of unspecified kidney, except renal  pelvis
593.2 Renal Cyst N28.1 Cyst of kidney, acquired
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2014 GEM 
185 Prostate Cancer C61 Malignant neoplasm of prostate
600.01 BPH w/ obstruction N40.1 Enlarged prostate with lower urinary tract symptoms
600.00 BPH w/o obstruction N40.0 Enlarged prostate without lower urinary tract symptoms
601.0 Prostatitis, Acute N41.0 Acute prostatitis
601.1 Prostatitis, Chronic N41.1 Chronic prostatitis
602.3 Dysplasia of prostate N42.3 Dysplasia of prostate
790.93 Elevated PSA R97.2 Elevated prostate specific antigen [PSA]
ICD-9 GEM Crosswalk
2014 GEM 
Bladder Cancer (.0)Trigone (.1) dome (.2) lateral wall (.3)  anterior wall (.4) posterior wall (.5) bladder neck (.6) ureteric  orifice (.7) urachus (.8) overlapping sites (.9) unspecified
595.0 Acute cystitis N30.00 Acute cystitis without hematuria
N30.01 Acute cystitis with hematuria
595.1 Interstitial Cystitis N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
595.2 Other chronic cystitis N30.20 Other chronic cystitis without hematuria
N30.21 Other chronic cystitis with hematuria
596.51 OAB N32.81 Overactive bladder
596.54 Neurogenic Bladder N31.0 Uninhibited neuropathic bladder, not elsewhere classified
N31.1 Reflex neuropathic bladder, not elsewhere classified
N31.9 Neuromuscular dysfunction of bladder, unspecified
GEM Crosswalk
2014 GEM 
598.1 Traumatic urethral stricture N35.010 Posttraumatic urethral stricture, male, meatal
N35.011 Posttraumatic bulbous urethral stricture
N35.012 Posttraumatic membranous urethral stricture
N35.013 Posttraumatic anterior urethral stricture
N35.014 Posttraumatic urethral stricture, male, unspecified
N35.021 Urethral stricture due to childbirth
N35.028 Other posttraumatic urethral stricture, female
598.9 Urethral stricture, unspecified N35.9 Urethral stricture, unspecified
599.0 Urinary tract infection, site not specified N39.0 Urinary tract infection, site not specified
599.71 Gross hematuria R31.0 Gross hematuria
599.72 Microscopic hematuria R31.1 Benign essential microscopic hematuria
R31.2 Other microscopic hematuria
604.9 Orchitis and epididymitis, unspecified N45.1 Epididymitis
N45.2 Orchitis
2014 GEM 
N47.1 Phimosis
N47.2 Paraphimosis
N47.5 Adhesions of prepuce and glans penis
N47.7 Other inflammatory diseases of prepuce
N47.8 Other disorders of prepuce
607.84 Impotence of organic origin N52.01 Erectile dysfunction due to arterial insufficiency
N52.02 Corporovenous occlusive erectile dysfunction
N52.03 Combined arterial insufficiency and corporovenous occlusive erectile  dysfunction
N52.1 Erectile dysfunction due to diseases classified elsewhere
N52.2 Druginduced erectile dysfunction
N52.31 Erectile dysfunction following radical prostatectomy
N52.32 Erectile dysfunction following radical cystectomy
N52.33 Erectile dysfunction following urethral surgery
N52.34 Erectile dysfunction following simple prostatectomy
N52.39 Other postsurgical erectile dysfunction
N52.8 Other male erectile dysfunction
N52.9 Male erectile dysfunction, unspecified
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2014 GEM 
N43.41 Spermatocele of epididymis, single
N43.42 Spermatocele of epididymis, multiple
608.9
Unspecified  disorder of male  genital organs N50.9 Disorder of male genital organs, unspecified
R10.2 Pelvic and perineal pain
625.6
724.2 Lumbago M54.5 Low back pain
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2014 GEM 
788.21 Incomplete  bladder emptying R39.14 Feeling of incomplete bladder emptying
788.31 Urge incontinence N39.41 Urge incontinence
788.33
788.41 Urinary frequency R35.0 Frequency of micturition
788.43 Nocturia R35.1 Nocturia
R10.9 Unspecified abdominal pain
Incident to Billing
• Medicare definitions:
• “Incident to” services are defined as services commonly  furnished in a physician’s office which are “incident to” the  professional services of a physician (MD or DO) and are  limited to situations in which there is direct physician personal  supervision. 
• Direct supervision for the physician office does not require to  physician to be present in the room when the patient is seen  nor does it require physician patient contact.  However, the  physician reporting the service (billing provider) must be in  the facility and immediately available when services are  provided.
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Incident to Billing  Office
• The plan of care for the patient must be established  during a visit in which the physician has direct  patient contact and clearly documents a plan of care  for the problem.  This does not mean that on each  occasion of an incidental service performed by an  NPP, that the patient must also see the physician. It  does mean there must have been a direct, personal,  professional service furnished by the physician to  initiate the course of treatment of which the services  being performed by the NPP is an incidental part. 
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Incident to Billingoffice
• TRANSLATION:  
• NPP cannot see new patients or established patients with a new  problem and bill“incident to”
• Some carriers have interpreted this guideline to mean that any change in treatment plan not initiated during a visit in which the physician is an integral part of the service (direct contact required) that visit any subsequent visit for the care are no longer eligible for “incident to” billing.
• NOT ALL MEDICARE MACs AGREE completely. ALL agree that any significant change in treatment or encounter for a new problem do not qualify for “incident to” service billing.
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Incident to Billing not allowed in  the Hospital
• Services and supplies that would normally be  covered “incident to” in an office setting, such as  NPs that the physician hires and supervises, are not  billable by the physician in hospital settings.
• If the physician uses the services of his/her own  employees in a hospital setting and the physician  merely supervises his/her services, the Service must  be reported under the NPP NPI.
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Incident to Billing
• May reimburse for nonphysician providers'  services differently
• Many state laws allow a general delegation of  authority with responsibility retained by the  physician without requiring onpremises  supervision. 
• Check contract and payer websites
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E&M coding “Take back” risk
• Medical Necessity
Documentation
• Separate and Unique documentation for  each service to be charged
• Forms / Templates
• Develop / Update
E&M   Documentation Cloning
–Office of Inspector General's ( OlG) Work Plan
– "Medicare contractors have noted an increased  frequency of medical records with identical  documentation across services,”
– "We will also review multiple E&M services for  the same providers and beneficiaries to identify  electronic health records [EHR] documentation  practices associated with potentially improper  payments.”
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Potential level 5– New Pt • Requires a complete Hx and PE
documented the following is a guide for each level.
• MDM • Patient w/acute sepsis in need of diagnostic tests to decide
treatment.
• Patient w/multiple lab tests, CT scan or x-ray requiring major surgery with identified risk factors
• Patient w/multiple active problems (stone and BPH and ED) requiring major surgery with identified risk factors
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Potential level 4– New Pt • Requires a complete Hx and PE
documented the following is a guide for each level.
• MDM • New problem to you with Rx drug ordered
• New problem with multiple lab and X-Ray test or a diagnostic endoscopy.
• New problem requiring lithotripsy either through scope or ESWL
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Potential level 3– New Pt
• You must have a 3rd level Hx and Detailed PE
• MDM
• New problem with 2 data points or an acute uncomplicated illness
• New problem with minor surgery no risk factors
• New problem with patient treated with over-the- counter drugs or physical therapy
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Modifier 25 and 57
• 25 Significant, separately identifiable E/M service by  the same physician on day of the procedure.”
• 57 Decision for Surgery: Append to an E/M service that resulted in the initial decision to perform the surgery.
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E&M modifiers Private Payer
• Not Required to follow Medicare and CPT  Rules   or Guidelines
• May Recognize Modifier 57 over with 0 and 10 Global
• ProceduresMay Require a separate diagnosis
• May use greater Global Periods
• May continue to pay for consultations
• Payers Involved in Class Action are required to Recognize CPT  modifiers
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I saw a patient on his initial visit for ED and initiated a plan. He saw the MD at the next visit and the MD stayed the course and did not change my plan. Since the MD now has seen the patient, may I bill “incident to” for subsequent visits?
Yes
No
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I am seeing an established patient for follow up and now he has a new complaint. Can I still bill “incident to?”
Yes
No
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I have a new patient with hematuria. Can I do a cystoscopy on her the same day and bill for both the new patient visit and the cystoscopy?
Yes
No
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I saw a new patient for incontinence. She is 82yo and has medicare. I did a UA, bladder scan and did a full Hx and PE including a pelvic exam. Her diagnosis was stress incontinence and atrophic vaginitis. I placed her on oxybutynin 5mg po qd and on estrogen cream and am having her f/u in 6 weeks to see the doctor for a reassessment. What is the correct code for the visit?
99203 99204 99205
Questions