Though ICD-10 implementation is going smooth so far, there are still concerns associated with orthopedic medical coding, particularly injury coding. Unlike ICD-9 codes, ICD-10 codes demand much more precise descriptions of the site of an injury. As a result, physicians need to provide more detailed documentation. Otherwise, there would be an increase in claim denials and significant drop in practice revenue. Against the backdrop of several reports featuring orthopedic practices facing a sudden rise of claim denials from Medicare, we will see the challenges related to ICD-10 orthopedic injury coding and the ways to overcome them.
The biggest problem physicians face when it comes to coding for injuries in ICD-10 is the difficulty to adjust to the increased specificity. Let’s consider the various challenges in detail.
New Coding Rules
Three coding rule changes in particular make ICD-10 medical coding for injuries tougher:
- The first is the seventh character extender that identifies whether the provider is seeing the patient who came to seek treatment for injury for the first time (initial), for a subsequent follow-up (subsequent) or due to a long-term sequela. There are seventh character extenders for fracture care as well. Several reports claim that software glitches tend to drop off the seventh character automatically and lead to increased claim denials.
- The second change is the use of three additional optional occurrence codes besides the codes that describe how the injury occurred. We will see this in detail later.
- The third change is a placeholder code ‘X’, which is used when the code needs a seventh character extender, but has fewer than six digits.
Logical Sequencing of Code Structure
ICD-10 code set is structured in a logical way, starting from the injuries to the head and then way down the body, to the toes. Some examples are:
- T20: Burn and corrosion of head, face, and neck
- T21: Burn and corrosion of trunk
- T22: Burn and corrosion of shoulder and upper limb, except wrist and hand
- T23: Burn and corrosion of wrist and hand
- T24: Burn and corrosion of lower limb, except ankle and foot
- T25: Burn and corrosion of ankle and foot
List the minor injuries first, followed by more serious trauma. Injuries to body areas are typically defined very specifically and with laterality. If the documentation indicates that the patient has multiple injuries and there is no code for such a situation, you should assign multiple codes – one for each injury. There is no need to use an aftercare code, if there is a seventh character.
Fracture Coding
For certain fractures, the seventh character is based on the Gustilo classification, identifying the level of soft-tissue damage. In certain other cases, the seventh character identifies whether the fracture is healing normally or there is a nonunion or malunion. The examples are as follows:
- S62.512D: Displaced fracture of proximal phalanx of left thumb, subsequent encounter for fracture with routine healing
- S62.512G: Displaced fracture of proximal phalanx of left thumb, subsequent encounter for fracture with delayed healing
- S62.512K: Displaced fracture of proximal phalanx of left thumb, subsequent encounter for fracture with nonunion
- S62.512P: Displaced fracture of proximal phalanx of left thumb, subsequent encounter for fracture with malunion
Once the injury is coded, choose a code that describes how the injury occurred. This is equivalent to E-code in ICD-9 and known as external cause codes (V01-Y99). The use of external cause codes is optional and they are never used in the first position. There are additional three occurrence codes, which are also optional. They identify the place of occurrence or where the patient was at the time of injury, what the patient was doing and whether the patient was injured at work, in the military, or was a civilian doing a volunteer activity
Tips to Resolve ICD-10 Coding Challenges
- Restrict the Use of Unspecified Codes – Coding an injury as unspecified may be justified in certain cases. However, it may also suggest insufficient documentation. Try to limit the use of unspecified codes and also make sure that the documentation is complete and accurate to justify the use of an unspecified code.
- Monthly Reports – Running monthly reports will reveal what codes your orthopedic practice uses most frequently. With this, you can make sure there is no overuse of unspecified codes.
- Customize Coding – Rather than relying completely upon EHRs, customize the coding process according to the particular condition. For example, ICD-10 coding for osteoporosis and fractures is entirely different as the former requires age-related information while the latter requires gustilo classification. The service of experienced and certified medical coders is advisable to ensure that the correct codes are assigned.
- Enhanced Communication – There must be clear and open communication between the physicians and coders to make workflow more efficient. This will help the providers to better understand the level of documentation required to file an accurate claim and the coders to choose the most appropriate codes without spending too much time for clarification.
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.