Anesthesiology ICD-10 Documentation Tips

by | Published on Dec 14, 2016 | Medical Coding

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Success in physician billing services under ICD-10 depends on proper clinical documentation and this is critical for anesthesiology. In addition to obtaining higher reimbursement, changing healthcare payment models also make it necessary for anesthesiologists to validate diagnosis with focused documentation. In anesthesiology, ICD-10 codes go beyond ICD-9 codes by:

  • Differentiating between the anesthesia services for low-acuity patients and high-acuity patients
  • Recognizing complexity of anesthetic services for simple surgical procedures which are provided to patients who have risk factors like obesity, diabetes or hypertension

These aspects make anesthesia medical coding and billing more complex, which is why most anesthesiologists prefer to rely on outsourced services provided by medical billing companies.

Physicians need to provide details in the documentation so that coders can select the right codes on claims submitted for payment. Diagnosis documentation should indicate:

  • Degree of disease – stage and phase
  • Anatomic specificity – for e.g., which specific wrist bone
  • Causation – whether the result of a pre-existing condition
  • External causes of injuries – for e.g., whether it involved machinery or if it occurred during sports

Here is a list of the top ICD-10 anesthesiology codes and related documentation tips:

    • Lumbar Radiculopathy: Thoracic/lumbar radiculopathy requires greater specificity in documentation than in ICD-9. Documentation for the following ICD-10 codes should indicate the precise anatomical location:
      • M54.14 – Radiculopathy, thoracic region
      • M54.15 – Radiculopathy, thoracolumbar region
      • M54.16 – Radiculopathy, lumbar region
      • M54.17 – Radiculopathy, lumbosacral region
    • Osteoarthritis, unspecified whether generalized or localized, lower leg: In ICD-10, Osteoarthritis (of any joint) is categorized based on type (Primary, Post-Traumatic or Secondary) and further classified by laterality (Unspecified, Right, Left or Bilateral). When both knees are affected, the default code option is primary osteoarthritis, and when only one knee is affected, it is unspecified type. Examples:
      • M17.0 Bilateral primary osteoarthritis of the knee
      • M17.10 Unilateral primary osteoarthritis, unspecified knee
      • M17.11 Unilateral primary osteoarthritis, right knee
      • M17.12 Unilateral primary osteoarthritis, left knee
      • M17.2 Bilateral post-traumatic osteoarthritis of the knee
      • M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee
      • M17.31 Unilateral post-traumatic osteoarthritis, right knee
      • M17.32 Unilateral post-traumatic osteoarthritis, left knee
    • Normal Vaginal Delivery: While ICD-9 did not have codes for number of weeks or trimester specification for obstetrical services, under ICD-10, the specific number of weeks can be added for all pregnancy diagnosis codes including for normal delivery.ICD-10 Code: O80 Encounter for full-term uncomplicated delivery. Other codes related to the outcome of delivery:
      • Z37.0 Single Live Birth
      • Z37.1 Single Stillbirth
      • Z37.2 Twins, Both Liveborn
      • Z37.3 Twins, One Liveborn and One Stillborn
      • Z37.4 Twins, Both Stillborn
      • Z37.9 Outcome of Delivery Not Specified

      Number of Weeks

      • Z3A.00 Weeks of Gestation of Pregnancy Not Specified
      • Z3A.01 Less than 8 Weeks Gestation of Pregnancy
      • Z3A.XX. where XX = the Number of Weeks Gestation
    • Cataract: Cataract that is specifically defined is further defined by laterality. The specified types commonly seen in anesthesiology include:

      ICD-10 Code:

      • H26.9 Unspecified Cataract
      • H25.10 age-related nuclear cataract, unspecified eye
      • H25.11 age-related nuclear cataract, right eye
      • H25.12 age-related nuclear cataract, left eye
      • H25.13 age-related nuclear cataract, bilateral (Age-related = senile)
      • H25.9 unspecified age-related cataract (senile)
      • H26.101 unspecified traumatic cataract, right eye
    • Abdominal Pain, Unspecified Site: For Abdominal Pain, Unspecified Site, ICD-10 allows three important elements to be documented for specific coding – location, laterality and type of pain.
      • ICD-10: R10.9 Unspecified Abdominal Pain

      Other related codes with greater specificity:

      • R10.0 Acute abdomen pain
      • R10.10 Upper abdominal pain, unspecified
      • R10.11 Right upper quadrant pain
      • R10.12 Left upper quadrant pain
      • R10.13 Epigastric pain
      • R10.2 Pelvic and perineal pain
      • R10.30 Lower abdominal pain, unspecified
      • R10.31 Right lower quadrant pain
      • R10.32 Left lower quadrant pain
      • R10.33 Periumbilical pain
      • R10.84 Generalized abdominal pain

Anesthesiologists need to communicate with other members of the surgical team to prevent discrepancies in coding which could lead to unsupported ICD-10 codes, causing payment delays and denials. By applying their knowledge of ICD-10 coding guidelines, medical procedures, and medical policies, expert coders in a reliable medical coding company help ensure coding accuracy and also provide anesthesiologists with proactive review to identify gaps in clinical evidence and documentation.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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