Medical Specialties with Complex Coding Challenges under ICD-10

by | Last updated Jun 14, 2023 | Published on Aug 3, 2016 | Medical Coding

Medical Specialties
Share this:

Now that ICD-10-CM implementation is well on its way, it is evident as to how various specialties have been affected by the changes. Providers can ensure appropriate reimbursement only by documenting diagnoses in sufficient detail or a higher level of specificity to support the new codes. Many physicians are choosing to rely on professional medical coding services to accomplish this, more so specialists in radiology, pediatrics, orthopedics, ophthalmology, cardiology and nephrology who face certain unique payment challenges due to changes under ICD-10.

  • Radiology: In ICD-10, radiologists need to provide greater details on medical history and indications for an exam for the purposes of precertification, dictation, and medical billing. Details such as laterality and specific anatomical location must also be included. The radiologist’s ability to appropriately bill for ordered services also depends on the provision of strong documentation by the ordering physician. Detailed and timely review of denials pertaining to medical necessity and Local Coverage Determinations (LCDs) is also critical for radiology practices to ensure steady cash flow.
  • Orthopedics: Injury and musculoskeletal codes have been expanded under ICD-10, resulting in a lot of new codes for orthopedic physicians. Some key changes include:
    • Laterality—specifying right, left, or bilateral
    • Site specificity. For example, for diagnosis of spinal conditions such as spondylosis (M47.-), spinal stenosis (M48.0-), and osteomyelitis (M46.2-), documentation should include the specific region of the spine such as: occipito-atlanto-axial, cervical, cervicothoracic, thoracic, thoracolumbar, lumbar, lumbosacral, sacral and sacrococcygeal, or multiple sites.
    • Place of occurrence codes (Y92)—specifying the place where the injury occurred. For e.g., Y92.126 denotes garden or yard of nursing home and Y92.531 denotes healthcare provider office.
  • Pediatrics: ICD-10 has significantly increased the volume of codes for pediatrics. A study conducted by the University of Illinois at Chicago (UIC) found that pediatricians are at a higher risk of revenue and data loss if ICD-10 codes are not used properly. The team found that pediatrics medical billing and coding has become quite difficult as about 26% of the codes commonly used by pediatricians requires complex mapping and is prone to error.
  • Nephrology: In ICD-9, Chronic Kidney Disorder (CKD) had only one code, but in ICD-10, there are five different codes for the condition. Hypertensive chronic kidney disease has two codes – the first indicating both hypertension and CKD, and the second specifying the level of CKD.
  • Cardiology: ICD-10 has many new cardiology-specific procedure codes. Risks of miscoding are quite high. For example, AMI of the anterolateral wall which was coded as 410.00 for an unspecified episode of care in ICD-9 has changed to I21.09 in ICD-10, which has no association with the episode of care.
  • Ophthalmology: ICD-10 has resulted in new terms and more specificity including distinct codes for laterality for many eye conditions. For instance, conditions are listed as right eye, left eye, bilateral, or unspecified and conditions of the eyelids are again classified on the basis of whether they affect the right upper, left upper, right lower, or left lower eyelid. The volume of codes has increased considerably for glaucoma. If a patient has different types of glaucoma in each eye or if the disease is at different stages in each eye, 2 codes will be needed (one for each eye). In addition, the correct code to indicate laterality and stage has to be used. There are codes for infantile and juvenile cataracts, traumatic cataracts, drug-induced cataracts, and secondary cataracts.

With all these challenges, it is hardly surprising that medical specialists are choosing to outsource medical billing and coding to professional service providers. Established companies have teams that have undergone in-depth training and education on ICD-10-CM, and can help physicians of all specialties navigate the complexities of the new diagnostic codes to achieve optimal reimbursement.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

More from This Author