Preparing for the Next Phase of ICD-10

Anticipation is looming over the upcoming end of the ICD-10 “grace period”, which takes effect October 1st, 2016. In order to help your group prepare, let’s take a further look at what can be expected.

Why The Grace Period?

As the ICD-10 implementation date of 10/1/15 neared, CMS released additional guidance to allow for flexibility in the claims auditing and quality reporting process as physicians transitioned to ICD-10 and the technical and systematic changes it entailed. CMS stated that for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.

What To Expect after October 1, 2016?

CMS recently released an update with a FAQ on the ICD-10 grace period which can be accessed here. The main points regarding the end of the grace period are below:

  • Document to the Highest Level of Specificity: Providers should avoid assigning unspecified ICD-10 codes whenever documentation supports a more detailed code.
  • Unspecified Codes Will Not Be Going Away: Unspecified codes are still active and often valid in ICD-10 after the grace period.

    Per CMS, “In ICD-10-CM, unspecified codes have acceptable, even necessary, uses….While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter. You should code each health care encounter to the level of certainty known for that encounter. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined).”

While it is now clear that the unspecified codes in ICD-10 will still exist and will also be necessary at times, it is still widely unknown if these codes will be considered medically necessary for certain exams. In an effort to minimize the risk of medical necessity denials, it is recommended that providers obtain as much detail regarding the clinical history and document to the highest level of specificity.

What are the Most Common Unspecified ICD-10 Codes Utilized in Radiology?

Over the past year, Advocate has been gathering data on the most common ICD-10 codes across all radiology groups. Of the top 10 diagnosis codes reported, two are unspecified: unspecified abdominal pain (R10.9) and chest pain, unspecified (R07.9).

It is important to remember that these unspecified codes may be appropriate and necessary. For simple x-rays and ultrasounds, there may be little else known regarding the patient’s pain. However, as the modality becomes more complex (and thus, more expensive), there should be more information available and documented pertaining to the patient’s condition, thus supporting the necessity of the study. Not surprisingly, coverage policies and medical necessity denials are typically directed toward more complex studies such as CT/MR, and Duplex studies.

Tips for improved documentation:

  • Abdominal Pain, Unspecified (R10.9)
    Most common exams: X-ray, Abdominal US, CT Abdomen/Pelvis

    • Specify location (Quadrant, periumbilical, epigastric)
    • Specify pain vs. tenderness
  • Chest Pain, Unspecified (R07.9):
    Most common exams: X-ray, CT, CTA

    • Specify location (Near throat, substernal, rib/intercostal, pleural)
    • Specify if associated with breathing
  • Always document a valid reason for exam. Terms such as “Rule out”, “MVA”, “MVC”, and “Fall” do not provide sufficient clinical information and lead to a vague ICD-10 code assignment. Again, for lower modality exams, this may not necessarily trigger a denial, but it is best practice to include the signs/symptoms/conditions warranting the study.

Is Your Practice at Risk for Increased Medical Necessity Denials?

Unfortunately, radiologists are at a particular disadvantage because of their lack of face to face time with the patient and inability to acquire a complete clinical history. Advocate has been providing education over the past 18 months in anticipation of these changes, and we continue to advise that in order for the ICD-10 transition to be successful for the radiologist, there must be a collaborative effort with the hospitals, technologists, and referring physicians to ensure the radiologist is obtaining the most accurate and specific clinical information for each patient. The below excerpt is from a previous ADVOCATE E-news, but still applies today:

Here are some basic strategies for radiologists to help ensure improved documentation required with ICD-10.

  • Develop awareness of poor clinical history (is it a specific location, technologist, referring physician, etc.). Communicate regularly if the clinical history is insufficient or incomplete.
  • Utilize any clinical documentation that is available in PACS, such as tech notes, check-in sheets, order, etc. Develop habits to review this information and dictate pertinent clinical history details in report.
  • Document laterality when appropriate.
  • Document specifics for fractures and injuries:
    • Specific site of fracture/injury
    • Type of fracture
    • Episode of care (is this a current fracture or followup/aftercare/malunion?)
  • Remember the basics of ICD-10 documentation. Whenever possible, document the following specifics:
    • ANATOMIC SITE
    • CONTEXT/SEVERITY/DURATION
    • ASSOCIATED CONDITIONS