Denials Chp 11 - Coding

Question 1

ICD-10-CM Coding

Answer 1

Background

ICD-10-CM was endorsed by the 43rd World Health Assembly in May 1990 and came into use in World Health Organization (WHO) Member States in 1994. The United States is a member of WHO. The classification is the latest in a series, which has its origins in the 1850s. The first edition, known as the International List of Causes of Death, was adopted by the International Statistical Institute in 1893. WHO took over the responsibility for the ICD at its creation in 1948 when the sixth revision, which included causes of morbidity for the first time, was published. The World Health Assembly adopted in 1967 the WHO Nomenclature Regulations that stipulate use of ICD in its most current revision for mortality and morbidity statistics by all Member States.

The ICD is the international standard diagnostic classification for all general epidemiological, many health management purposes, and clinical use. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality, and guidelines.

It is used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and health records. In addition to enabling the storage and retrieval of diagnostic information for clinical, epidemiological, and quality purposes, these records also provide the basis for the compilation of national mortality and morbidity statistics by WHO Member States.

The National Center for Health Statistics (NCHS) developed ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) in consultation with a technical advisory panel, physician groups, and clinical coders to assure clinical accuracy and utility. There are no codes for procedures in the ICD-10-CM and procedures are coded using the procedure classification appropriate for the encounter setting (for example, Current Procedural Terminology — or CPT® — and ICD-10-PCS).

ICD-10-PCS includes procedure codes and is typically used by facilities for inpatient services. Hospitals use ICD-10-PCS in the outpatient facility for tracking purposes only and do not use it to submit claims.

We will focus on the proper use of ICD-10-CM in this medical reference guide.

Question 2

Medical Necessity

Answer 2

One of the most important requirements to receive payment for services is to establish medical necessity. You must justify care provided by presenting the appropriate facts. Payers require the following information to determine the need for care:

1.Knowledge of the emergent nature or severity of the patient’s complaint or condition.

2.All signs, symptoms, complaints, or background facts describing the reason for care.

3.The facts must be substantiated by the patient’s medical record, and that record must be available to payers on request.

For example, a patient complains of pain in their right knee and the provider performs a knee X-ray. When the claim is submitted, the payer needs to know why the service was performed. The diagnosis code on the claim will indicate the reason or the medical necessity. In this example, we select a code to report the X-ray with a diagnosis code for knee pain to support the reason the service was performed. We will discuss the proper selection of diagnosis (ICD-10-CM) codes later in this chapter.

Question 3

Overview of ICD-10-CM Layout

Answer 3

ICD-10-CM is published in two sections:

1.Alphabetic Index or Index to Diseases and Injuries: Diagnostic terms organized in alphabetic order for the diseases found in the Tabular List. The terms Alphabetic Index and Index to Diseases and Injuries are used interchangeably throughout this text.

2.Tabular List: Diagnosis codes organized in numerical order and divided into chapters based on body system or condition.

All coders use ICD-10-CM to assign diagnosis codes that establish medical necessity for services rendered. For example, a patient has a bad cough and congestion. The provider performs a chest X-ray. On the claim form, the coder assigns diagnosis codes for the documented cough and congestion, which support the service.

Establishing medical necessity is the first step in third-party reimbursement. Payers require the following information to determine the need for care:

1.Knowledge of the emergent nature or severity of the patient’s complaint or condition.

2.All signs, symptoms, complaints, or background facts describing the reason for care are facts that must be substantiated by the patient’s medical record and must be available to payers on request.

Question 4

Tabular List

Answer 4

The Tabular List is a numerical listing of disease and injury. There are 22 chapters for the classification of diseases and injury, grouped by etiology (cause) or anatomical (body) site. The Tabular List is organized in three-character category codes and their titles. Some three-character codes are very specific and are not subdivided. These three-character codes can stand alone to describe the condition being coded. Most three-character categories (rubrics) have been subdivided with the addition of a decimal point, followed by up to four additional characters.

Each character for all categories, subcategories, and codes may be either a letter or a number. Codes can be three to seven characters in length. The 1st character of a category is a letter, followed by two additional characters that may be either numbers or alpha characters. Subcategories have an additional four to seven alphanumeric characters and the 7th character is called an extension (discussed later in this chapter). The 4th character in an ICD-10-CM code further defines the site, etiology, and manifestation or state of the disease or condition. To help describe the disease to the highest level of specificity, the subcategory includes the three-character category plus a decimal with an additional character. The 5th or 6th character subclassifications further represent the most accurate level of specificity regarding the patient’s condition or diagnosis. Certain ICD-10-CM categories require seven characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. If a code is three, four, or five characters, but requires a 7th character extension, a placeholder X must be used to fill the empty spaces in the code. There are symbols throughout the Tabular List to identify when a code requires an additional character.

Examples:

√ 4th E03 Other Hypothyroidism

√ 5th H21.4 Pupillary membranes

√ 6th I87.00 Postthrombotic syndrome without complications

√ 7th O32.0 Maternal care for unstable lie

Question 5

Index to Diseases and Injuries

Answer 5

Main terms in the Alphabetic Index usually reference the disease, condition, or symptom. Subterms modify the main term to describe differences in site, etiology, or clinical type. Subterms add further modification to the main term

Question 6

Conventions

Answer 6

Boldface

Boldface type is used for all codes and titles in the Tabular List and main terms in the Alphabetic Index.

EXCLUDES1 A type 1 excludes note represents that the condition is not coded here. This note indicates that the code excluded should not be used at the same time as the code above the Excludes1 note if the conditions are related. An Excludes1 note can indicate when two conditions should not be reported together, such as a congenital form versus an acquired form of the same condition. An example, category code H26 Other cataract has the Excludes1 note that lists the condition congenital cataract (Q12.0). Because the codes are for the same condition, cataracts, you should not report a code from H26 (acquired condition) with code Q12.0 (congenital condition). If the patient has congenital cataracts report code Q12.0, not a code from category H26.

In some cases, the conditions listed may be used together when the conditions are unrelated to one another. For example, the Excludes1 note at subcategory code S02.85-, indicates codes from S02.3- (fracture of orbital floor) and S02.12- (fracture of orbital roof) should be reported for those types of fractures and not to use a code from subcategory S02.85-. If there was a fracture of the orbit of the left eye and a fracture of the orbital roof of the right eye, both codes may be used together.

Question 7

EXCLUDES2 A type 2 excludes note represents that the condition is not included here. A type 2 excludes note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When a type 2 excludes note appears under a code, it is acceptable to use both the code and the excluded code together.

Answer 7

INCLUDES The Includes note appears immediately after a three-character code title to further define or clarify the category.

Question 8

Use additional code

Answer 8

This instruction signals the coder an additional code should be used, if the information is available, to provide a more complete picture of the diagnosis.

Question 9

Code first

Answer 9

This instruction is used in categories not intended to be the principal diagnosis. The note requires the underlying disease (etiology) be recorded first and the manifestation be recorded second. The Code first note appears only in the Tabular List.

Question 10

Use additional code, if applicable

Answer 10

The causal condition note indicates this code may be assigned as a diagnosis when the causal condition is unknown or not applicable. If a causal condition is known, the code should be sequenced as the principal diagnosis.

Question 11

Combination code

Answer 11

This is when a single code is used to classify two diagnoses, a diagnosis with an associated secondary process (manifestation), or a diagnosis with an associated complication.

Question 12

Eponym

Answer 12

This term indicates the code describes a disease or syndrome named after a person. An example is Lou Gehrig’s disease. Lou Gehrig was a famous baseball player who was diagnosed with what is also known as amyotrophic lateral sclerosis (ALS).

Question 13

Modifiers

Answer 13

Essential modifiers are subterms listed in the Alphabetic Index below the main term in alphabetical order and are indented two spaces. Nonessential modifiers are subterms that follow the main term and are enclosed in parentheses; they can clarify the diagnosis but are not required.

Question 14

Notes

Answer 14

Notes are used to define terms, clarify information, or list choices for additional characters.

Question 15

Other

Answer 15

Other or other unspecified codes are used when the information in the medical record provides detail for which a specific code does not exist. Index entries with NEC in the line designate other codes in the Tabular List. These index entries represent specific disease entities for which no specific code exists, so the term is included within the other code.

Question 16

See

Answer 16

This instruction directs you to a more specific term under which the correct code can be found.

Question 17

See also

Answer 17

This indicates additional information is available that may provide an additional diagnosis code.

Question 18

See category

Answer 18

See category indicates that you should review the category specified before assigning a code.

Question 19

Unspecified

Answer 19

Unspecified codes are used when the information in the medical record is not available for coding more specifically and should only be selected when there is no other option. For example, if the provider documents hyperfunction of the pituitary gland without additional information as to the cause or type of pituitary gland hyperfunction, the only option is an unspecified code E21.3 Hyperparathyroidism, unspecified.

Question 20

And

Answer 20

The word “and” in a code description can mean either “and” or “or.” For example, code A52.75 Syphilis of kidney and ureter.

Question 21

With

Answer 21

In the ICD-10-CM Alphabetic Index the word “with” is listed immediately under the main term, not in alphabetical order. Terms indented under the term “with” in the Alphabetic Index (either under a main term or a subterm) are presumed to have a causal relationship between the two conditions. Only if the documentation specifically states the conditions are not related, the conditions would be reported separately, and a causal relationship is reported.

Question 22

Steps to Look Up a Diagnosis Code

Answer 22

Determine the main term of the diagnosis documented in the medical record. It is important for a coder to have a solid foundation in medical terminology and anatomy to effectively review the medical record and determine the documented diseases/conditions that should be reported.

Look up the main term in the Alphabetic Index. The main term is the disease, illness, or condition of the patient. Review all subterms to determine the most specific code. Review all see and see also notes.

Refer to the code referenced in the Alphabetic Index in the Tabular List. Review all Includes, Excludes1, Excludes2, and Use additional code notations to verify the accuracy of the code. The notations and conventions in the ICD-10-CM code book provide hints to the coder when a more appropriate code should be reported. Throughout the next chapter, we will discuss the coding guidelines that include rules for proper ICD-10-CM code selection and sequencing.

Following the steps to look up diagnosis codes is extremely important to verify accuracy.

Question 23

Question: What steps should I take when I receive a denial for an invalid ICD-10-CM code?

Answer 23

Answer: When a diagnosis or procedure code is missing or invalid, the claim may be denied with one of the following reasons:

This service is not covered when performed with an invalid diagnosis code.
This principal diagnosis code is invalid. The provider must submit a valid code.
This diagnosis code or procedure code is not valid for the date of service on the claim.
A diagnosis code(s), which meets medical necessity for the procedure code is missing or invalid.
This procedure code is not valid or not valid for the service date on the claim line.
Verify reported procedure and diagnosis codes that indicate the highest level of specificity and are valid for the reported date of service. If necessary, correct the codes and resubmit the claim.
Diagnosis codes are invalid or truncated. Diagnosis codes are typically updated each year. In addition, diagnosis codes must be coded to the highest level of specificity. If a code requires seven characters, all seven characters should be listed for the code to be valid. For example, a traumatic displaced fracture of the head of the left radius, initial visit, would require seven characters (S52.122A). Only reporting S52.122 would be considered a truncated code

Question 24

Question: Can you help me understand the difference between an Excludes1 note and an Excludes2 note?

Answer 24

Answer: In the Conventions section of the ICD-10-CM code book, in the guidelines, there are important instructional notes listed that will help a biller ensure that the appropriate codes have been chosen.

Includes notes: This note appears immediately under a three-character code title and provides further definition or gives examples.

Excludes notes: There are two types of Excludes notes. Each type of note has a different definition for use. They are similar in that they indicate that codes excluded from each other are independent of each other.

A type 1 Excludes note represents that the condition is “not coded here.” This note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 note indicates when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Conditions listed with Excludes1 are mutually exclusive.

An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider. For example, code F45.8 Other somatoform disorders has an Excludes1 note for sleep-related teeth grinding (G47.63), because teeth grinding is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However, psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep-related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together.

A type 2 Excludes note represents that the condition is not included here. An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together.