Jennifer Hayes, DNP, FNP-BC, CPC, CPCOManager, Medical CodingHealthcare Clinic at Walgreens

The presenter has no disclosures or conflict of interest to report.

No off-label prescribing will be discussed.

Review key CMS directives in ICD-10 coding

Identify payer requirements for code submission

Evaluate key strategies for coding success

Additional Coding RulesRequire additional diagnosis codes

Caution with EHR

Payer AnalyticsBetter analysis of diagnosis pairing

Unspecified diagnoses

Stringency versus LeniencyCode families

Specificity

Medicare Fee-for-service Part B Fee Schedule only

Any valid code from correct code family acceptable

www.icd10data.com:

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf

The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided

Services provided have been accurately reported

If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred

The CPT and ICD-10-CM codes reported on the health insurance claim form should be supported by the documentation in the medical record

CMS 1997 DOCUMENTATION GUIDELINES FOR EVALUATION & MANAGEMENT SERVICES

CMS Bell-curve expectations

Family Practice:

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareFeeforSvcPartsAB/downloads/EMSpecialty2012.pdf?agree=yes&next=Accept

0

10

20

30

40

50

99201 99202 99203 99204 99205

New Visit %

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10

20

30

40

50

60

99211 99212 99213 99214 99215

Established Visit %

Coding rules can impact E/M code if not careful

Some diagnoses require 2 codes

Some diagnoses cannot be used together

Better capture of disease severity in diagnosis codes

Combination codes for complications

Coding Tip: Rules Rule!

Being familiar with Excludes1 coding rules

will help avoid mismatch of diagnosis codes

FederalMedicare

StateMedicaid

CommercialPrivate Insurers

Includes Healthcare Marketplace plans

Medicare Advantage

CPT codes

Procedures performed

Additional testing

Screening

(Medicare coverages)

Coding Tip: Less is More!

Know coverages for your payers in order to

perform testing that will support selected treatment plan

Supported by documentation

Provide clinical picture with diagnosis listing

Supports quality of care

Minimizes claim denial

Do not support medical necessity

Many payers rejecting diagnoses containing “unspecified”

Risk Adjustment not correctly captured

Value Based Care Model

Coding Tip: 1-Strike Rule

Avoid diagnosis codes that use the word

“unspecified” more than once in description

Diagnosis that represents the main reason the patient sought medical care

Certain coding rules prevent some diagnoses from being designated as primary

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Certain Z-Codes:

BMI

Family history codes

Personal history codes

Z16- (drug resistance)

External Cause Codes

Chapters V00-Y99

Certain Supplemental Codes

(Chapters A00-B99)

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HTN

Diabetes

Asthma

Etiology

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Provider documentation

Lab and diagnostic test results

Previous medical records

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Evidence-based Medically Necessary

HPI

Pertinent positive findings for chief complaint

Individual elements Interval from last follow-up Chronic Condition status PE

Follows EBP guidelines Includes all affected organ

systems from HPI and ROS Examine for all potential

complications

ROS

Inventory of impacted organ systems

Pertinent positive and negative findings

Extension of presenting problem and underlying conditions

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More Specific

E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease

N18.2 Chronic kidney disease, stage 2

Z79.4 Long term (current) use of insulin

J45.30 Mild persistent asthma, uncomplicated

Less Specific

E11.9 Type 2 diabetes mellitus without complications

J45.909 Unspecified asthma, uncomplicated

“Site not specified”

Unknown organism

Descriptor for code

UNSPECIFIED

UNSPECIFIED

EBP supports consistencyMeets standard of care requirements

Quality of care provided is consistent

Be cautious of cloningNo 2 patients will present exactly the same way for the same condition

Under-documenting per EBP will result in under-coding

Over-documenting outside of EBP will result in over-coding not supported by medical necessity

Appropriate history is building block for remainder of visit

Not just coding, but also quality of care

Patient presents for checkup with PCP. Has diabetes and HTN and has not been seen in almost 2 years. Has intermittently taken meds if had refills remaining. Recently quit smoking since retiring from work 4 months ago and wants to get back on track with health to enjoy being active in retirement.

CC: Annual check-up

HPI: Patient with uncontrolled hypertension and uncontrolled Type II diabetes. Recently on Medicare due to retirement and wishing to get control of chronic conditions. Had been treated in the past with insulin for diabetes but has only been sporadically taking Metformin and has not used insulin in over a year. A1C 2 years ago was 9.4

PMH: Diabetes, hypertension

FMH: Thyroid cancer – mother; Diabetes – mother; COPD -

sister

Social history: Quit smoking 7 months ago

Constitutional: Denies significant changes in weight

Eyes: No change in vision other than cataracts

Respiratory: Denies cough or SOB

CV: Denies chest pain, palpitations; denies swelling in feet

Neuro: Reports has had some increased foot pain bilaterally; denies any headache; denies any weakness

GU: Reports more frequent urination over past 6 months, waking up more at night

GI: Denies any change in appetite; denies abdominal pain

M/S: Denies any M/S issues

Skin: Denies any sores, dry skin or ulcers

Vitals and General Appearance:

Temp: 99.0; Resp: 21; BP 152/88 (Lt. Arm); 158/90 (Rt. Arm) Pulse: 70; Ht. 6’1”; Wt. 260; BMI 34.3

Appears to be in NAD

HEENT:

Eyes: EOM’s intact; funduscopic exam WNL

Mouth/Throat/Dentition: Lips, teeth, gums WNL

Neck: No thyroid enlargement seen; no carotid bruit

Abdomen:

No organomegaly; no abdominal bruit

Respiratory:Lungs clear to auscultation; respirations unlabored

Cardiovascular:Regular heart rate and rhythm, without murmur, no abnormal or extra heart sounds; 2+ pedal edema; pedal pulses WNL

Neuro:Monofilament reveals diminished sensation on foot exam; DTR’s intact

Skin:No ulcers or skin lesions identified; hammer toe on second digit of left foot

Random glucose: 348

EKG: Normal

Urinalysis: + Glucose; + Ketones

Medical Necessity?

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Additional labs

Screening tests

Key Considerations:Plan exclusions?

ABN or not?

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E11.21 Type 2 diabetes mellitus with diabetic nephropathy

E11.36 Type 2 diabetes mellitus with diabetic cataract

E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy

E11.621 Type 2 diabetes mellitus with foot ulcer

E11.65 Type 2 diabetes mellitus with hyperglycemia

E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy

E11.21 Type 2 diabetes mellitus with diabetic nephropathy

E11.36 Type 2 diabetes mellitus with diabetic cataract

E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy

E11.621 Type 2 diabetes mellitus with foot ulcer

E11.65 Type 2 diabetes mellitus with hyperglycemia

E11.36 Type 2 diabetes mellitus with diabetic cataract

I11.0 Hypertensive heart disease with heart failure

I11.9 Hypertensive heart disease without heart failure

I15.0 Renovascular hypertension

I10 Essential (primary) hypertension

I15.8 Other secondary hypertension

I10 Essential (primary) hypertension

Z68.34 Body mass index (BMI) 34.0-34.9, adult

E66.01 Morbid (severe) obesity due to excess calories

E66.9 Obesity, unspecified

E66.3 Overweight

E66.9 Obesity, unspecified

Z68.34 Body mass index (BMI) 34.0-34.9, adult

F17.200 Nicotine dependence, unspecified uncomplicated

F17.210 Nicotine dependence, cigarettes, uncomplicated

F17.290 Nicotine dependence, other tobacco product, uncomplicated

Z72.0 Tobacco use

Z87.891 Personal history of nicotine dependenceZ87.891 Personal history of nicotine dependence

New category in ICD-10

Gives payers view of gaps in care

Identification of population health issues

For this patient, category:

T38.3X6- Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs

Diagnosis CodesE11.41 (Diabetes w/mononeuropathy)

E11.36 (Diabetes w/cataract)

I10 (HTN)

E66.9 (Obesity)

Z68.34 (BMI)

Z87.892 (History of nicotine)

T38.3X6A (Underdosing of insulin)

CPT Codes99214

93000 (EKG)

81000 (Urinalysis)

82962 (Glucose)

Labs reveal:

GFR: 88

Hgb A1C: 10.2

How does this change the diagnosis codes?

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E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy

E11.36 Type 2 diabetes mellitus with diabetic cataract

E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease

N18.2 Chronic kidney disease, stage 2 (mild)

Z79.4 Long term (current) use of insulin

I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

N18.2 Chronic kidney disease, stage 2 (mild)

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