Dealing with Some Complex Instances of ICD-10 Coding

by | Published on Mar 23, 2016 | Medical Coding

ICD 10 Coding
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Medical billing and coding consumes much of the attention of medical staff. When medical situations of a certain complexity arise, the challenge rises as to how to code the diagnosis well so as to ensure timely reimbursement.

The new ICD-10-CM codes are known for their complexity and greater detail. The AAPC had stated back in 2014, before the new codes were made mandatory on October 1, 2015, that the implementation of the ICD-10 coding system would change coding and would also take a bit of effort to implement. Physician practices particularly struggled to get accustomed to the increased number of codes, largely due to the changes they needed to make in their coding system and the lack of professional coders to handle the coding.

Increased Detailing for Efficient Coding

The increased detailing, which has resulted in more codes to deal with, has been introduced to ensure more accurate documentation of the health condition and the associated signs and symptoms. While the ICD-9-CM system contained only 14,025 diagnosis codes, ICD-10-CM features about 69, 823. However, once practices get used to the new system they’d find that the increased and more detailed codes actually make the coding more accurate and simpler too. More accuracy and specificity in medical billing and coding also helps reduce the number of claim denials. As you’ll see, the organization of these new codes is more logical and therefore easier to figure out, eventually.

Basic Aspects of ICD-10-CM

It is important to remember some of the crucial aspects of the new medical coding system. We’ll touch upon some of the doubts that physicians could have in dealing with certain conditions that demand innovative coding:

  • An ICD-10 code has a basic structure. It has three to seven characters in total. The first three characters represent category except when the first character is “U”. In the four last characters, the first three represent etiology, anatomic site and severity while the last character is the extension of the code for obstetrics, injuries as well as external injury causes.
  • Codes describing signs and symptoms, rather than diagnoses, can be used for reporting purposes if a definitive diagnosis regarding the condition has not been confirmed by the provider. It is important to remember that you should not assign additional codes to signs and symptoms routinely associated with a particular disease process, unless such an instruction is provided by the classification. Signs and symptoms not routinely associated with the process of a disease should be coded if they are present.

Combination Codes

Combination codes are used for classifying two diagnoses or a diagnosis having a secondary process, manifestation or complication associated with it. The combination code must only be assigned when it is able to fully depict the manifested diagnostic conditions or when it is so directed by the Alphabetic Index. Be careful not to use multiple coding when a combination code can clearly identify the manifested diagnostic conditions.  It is only when the combination code isn’t specific in describing the manifested condition should a secondary code be used.

Sequencing of Coding

It is also important to know the sequencing of coding. Physicians and hospitals may come across conditions in patients where there is an underlying etiology as well as multiple manifestations in the body system as a result of that underlying etiology. ICD-10-CM guidelines indicate that the underlying condition must be sequenced first before the manifestation is sequenced. Let’s take an example from neoplasm.

  • Sequencing for Neoplasm: If a pregnant woman checks in with malignant neoplasm, the code from the subcategory 09A.1 for “malignant neoplasm complicating pregnancy, childbirth and the puerperium” must be sequenced first. This must be followed by the appropriate neoplasm code indicating the kind of neoplasm.

If the physician encounter is for managing a complication associated with neoplasm and the treatment is offered only for the complication, the complication needs to be first coded before the appropriate neoplasm code. If an encounter occurs for treating complications arising from surgery performed for neoplasm, the complication must be designated as the first-listed or principal diagnosis.

If primary neoplasm malignancy involves further treatment though it has been excised, the primary malignancy code must continue to be used till the completion of treatment. If the primary malignancy has been excised or eradicated previously and no further malignancy treatment is required, the appropriate code from the category Z85 for “Personal history of malignant neoplasm” must be used for indicating the former site of the malignancy.

If an encounter is for treating pathological fracture caused by neoplasm with the treatment focused on the fracture, the appropriate code from the M84.5 subcategory for “Pathological fracture in neoplastic disease” must first be sequenced followed by the neoplasm code. However, if neoplasm is the focus of treatment the neoplasm code must first be sequenced and then the code for pathological fracture must be sequenced.

  • Sequencing for Severe Sepsis: Here’s another instance of sequencing, this time involving severe sepsis. If the patient is suffering from severe sepsis on admission with the symptoms meeting the principal diagnosis requirements, the systemic infection at the root of the issue must be assigned as the principal diagnosis. Only then should the appropriate code from the R65.2 subcategory be assigned. An R65.2 subcategory code cannot be assigned as the principal diagnosis.

In the event of severe sepsis developing during an encounter after the admission, the underlying systemic infection along with the appropriate subcategory R65.2 code must be assigned as secondary diagnosis. If the documentation does not clearly state whether the patient had severe sepsis during admission, the provider will have to be queried.

Sequela Code

In some situations, you may need to use a sequela code.

  • Sequela refers to residual effects of a sickness or injury after its acute phase has ended. Such residual effects sometimes occur a few months later, or could also occur years later. As a result, no time limit has been imposed on using a sequela code.
  • Sequela coding usually requires two codes – the nature of sequela must be sequenced first, after which the sequela code must be sequenced.
  • There is an exception to this when the sequela code is followed by a Tabular List manifestation code and title, or when the sequela code is expanded, at the level of the fourth, fifth or sixth character, to include the manifestation. The code depicting the acute phase of a health condition which eventually led to sequela is not used with a code for the late effect.

With professional medical billing and coding services, physician practices can ensure accurate coding particularly in the aforementioned instances.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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