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Coding:ICD‐10 and Common Coding Questions

Mark N. Painter 

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Objectives

• Successfully adapt current coding and documenation practices to the New ICD‐10‐ CM system

• Properly bill “incident to” encounters 

• Determine coding for the appropriate level of MDM for evaluation and management services 

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ICD‐10 Preparation

• Designate a champion in the practice

• Check with vendor preparations

• Begin template redesign

• Think detail

• Reason, duration, cause, associated Dx, sequencing 

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ICD‐9‐CM vs ICD‐10‐CM OverviewICD‐9‐CM Diagnosis Codes ICD‐10‐CM Diagnosis Codes

Approximately 14,000 codes  Approximately 69,000 codes

3‐5 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

• Your EMR is going to have to change

– 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 ICD‐10, 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 ICD‐9‐CM• Alphabetic Index

– Index of disease and injury– Index of External Causes of Injury– Table of Neoplasms– Table of Drugs and ChemicalsOrganized by main term describing the disease and/or condition

• Tabular list – Body System– ConditionOrganized by chapters based on body system or condition – similar 

but differences

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ICD‐10‐CM TABULAR LIST of DISEASES and INJURIES ‐ Table of Contents

1 Certain infectious and parasitic diseases (A00‐B99) 

2 Neoplasms (C00‐D49) 

3Diseases of the blood and blood‐forming organs and certain disorders involving the immune mechanism (D50‐D89) 

4 Endocrine, nutritional and metabolic diseases (E00‐E89) 

5 Mental and behavioral disorders (F01‐F99)

6 Diseases of the nervous system (G00‐G99)

7 Diseases of the eye and adnexa (H00‐H59)

8 Diseases of the ear and mastoid process (H60‐H95)

9 Diseases of the circulatory system (I00‐I99)

10 Diseases of the respiratory system (J00‐J99)

11 Diseases of the digestive system (K00‐K94)

12 Diseases of the skin and subcutaneous tissue (L00‐L99)

13 Diseases of the musculoskeletal system and connective tissue (M00‐M99)

14 Diseases of the genitourinary system (N00‐N99)

15 Pregnancy, childbirth and the puerperium (O00‐O99)

16 Certain conditions originating in the perinatal period (P00‐P96)

17 Congenital malformations, deformations and chromosomal abnormalities (Q00‐Q99)

18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00‐R99)

19 Injury, poisoning and certain other consequences of external causes (S00‐T88)

20 External causes of morbidity (V00‐Y99)

21 Factors influencing health status and contact with health services (Z00‐Z99)

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XX

Category Etiology, anatomic site, severity

Added code extensions (7th

character) for obstetrics,

injuries, and external causes of

injury

ICD‐10‐CM Structure

X XN 4 0 3.

Additional Characters

Alpha (Except U)

2 Always Numeric3-7 Numeric or Alpha

3 – 7 Characters

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• Urolithiasis (N20‐N23)

• N20 Calculus of kidney and ureter – Calculous pyelonephritisExcludes1:  nephrocalcinosis (E83.5)

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

2014 GEM 

591Hydronephrosis N13.1

Hydronephrosis with ureteral stricture, not elsewhere classified

N13.2Hydronephrosis 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

C64.9Malignant 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

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2014 GEM 

188.9 Bladder CancerC67‐

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

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2014 GEM 

257.2 Hypogonadism E29.1 Testicular hypofunction

598.1 Traumatic urethral stricture N35.010 Post‐traumatic urethral stricture, male, meatal

N35.011 Post‐traumatic bulbous urethral stricture

N35.012 Post‐traumatic membranous urethral stricture

N35.013 Post‐traumatic anterior urethral stricture

N35.014 Post‐traumatic urethral stricture, male, unspecified

N35.021 Urethral stricture due to childbirth

N35.028 Other post‐traumatic 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

603.0 Encysted hydrocele N43.0 Encysted hydrocele

604.9 Orchitis and epididymitis, unspecified N45.1 Epididymitis

N45.2 Orchitis

N45.3 Epididymo‐orchitis

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2014 GEM 

605 Redundant prepuce and phimosis N47.0 Adherent prepuce, newborn

N47.1 Phimosis

N47.2 Paraphimosis

N47.3 Deficient foreskin

N47.4 Benign cyst of prepuce

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 Corporo‐venous occlusive erectile dysfunction

N52.03Combined arterial insufficiency and corporo‐venous occlusive erectile dysfunction

N52.1 Erectile dysfunction due to diseases classified elsewhere

N52.2 Drug‐induced 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 post‐surgical erectile dysfunction

N52.8 Other male erectile dysfunction

N52.9 Male erectile dysfunction, unspecified

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2014 GEM 

608.1 Spermatocele N43.40 Spermatocele of epididymis, unspecified

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

Stress incontinence, female N39.3 Stress incontinence (female) (male)

724.2 Lumbago M54.5 Low back pain

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2014 GEM 

788.1 Dysuria R30.0 Dysuria

R30.9 Painful micturition, unspecified

788.21Incomplete bladder emptying R39.14 Feeling of incomplete bladder emptying

788.31 Urge incontinence N39.41 Urge incontinence

788.33

Mixed incontinence (male) (female) N39.46 Mixed incontinence

788.41 Urinary frequency R35.0 Frequency of micturition

788.43 Nocturia R35.1 Nocturia

788.63Urgency of urination R39.15 Urgency of urination

789Abdominal pain, unspecified site R10.0 Acute abdomen

R10.9 Unspecified abdominal pain

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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 Billing‐office

• 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

• OTHER PAYERS

• May reimburse for non‐physician providers' services differently

• Many state laws allow a general delegation of authority with responsibility retained by the physician without requiring on‐premises supervision. 

• Check contract and payer websites

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E&M coding“Take back”‐ risk

• Medical Necessity

• “Cloning” of records

• Documentation

• Not signing encounters

• Misuse of modifiers

• Charges outside the norm

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Documentation

• Proof of Service

• Medical Necessity 

• Separate and Unique documentation for each service to be charged

• Forms / Templates

• Develop / Update

• Hx and PE

17

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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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26

E&M Coding tips‐ Time and/or Components

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27

AU

A C

od

ing

Se

min

ar S

erie

s 2

01

0

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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 onday of the procedure.”

• 57‐ Decision for Surgery:‐ Append to an E/M service that resultedin the initial decision to perform thesurgery.

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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

• Procedures‐May 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

Scenario 1

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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

Scenario 2

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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

Scenario 3

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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

Scenario 4

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Questions