1-Year Grace Period for ICD-10 Coding to End Soon

August 26, 2016

Nobody needs to go to medical school to know that people have two ears.

However, if physicians treat a patient with suppurative, or pus-discharging, otitis media, they don't have to specify left ear, right ear, or both — at least right now — when they choose an ICD-10 diagnostic code for the bill. They also don't have to specify whether it's a chronic or acute problem, or accompanied or not by a spontaneously ruptured ear drum. They can go with ICD-10 code H66.40 — unspecified suppurative otitis media, unspecified ear — as an all-purpose code.

Come October 1, though, physicians who treat otitis media had better choose a code that's specific on matters such as which ear and the like, assuming they document obvious details like that. Otherwise, a third-party payer like Medicare may bounce back the claim for having the wrong diagnostic code.

October 1 marks the end of a 1-year grace period that the Centers for Medicare and Medicaid Services (CMS) established for the new diagnostic codes called ICD-10. CMS will no longer accept unspecified ICD-10 codes on Medicare fee-for-service (FFS) claims when a specific one is warranted by the medical record. Several major health insurers that followed Medicare's lead on coding leniency are expected to get tougher as well.

The IDC-10 code set, which debuted October 1, 2015, allows clinicians to more precisely describe diseases and conditions than they could before. Using ICD-9, a hand surgeon operating on a broken wrist, for example, could specify which of the eight wrist bones was broken, and whether it was a closed or open fracture. That was it. ICD-10 codes go further, distinguishing between the right and left wrist. They also indicate whether the fracture was displaced or nondisplaced, whether the healing was routine or delayed on a follow-up visit, and whether there was fracture malunion or nonunion. For the scaphoid and hamate bones of the wrist, the codes zoom in on the fracture's location.

Other physicians, whether they toil in primary care, endocrinology, or oncology, can point to how the ICD-10 codes have fine-tuned their diagnoses. This greater specificity, however, makes the new code set harder to work with. After all, there are roughly five times as many ICD-10 codes as there are ICD-9 codes, and the new codes run to a maximum of seven characters compared with five for their predecessors.

Coding Catch-Alls That Could Catch Hell in October

Organized medicine feared that many physicians would commit a ton of diagnostic coding errors in their ICD-10 learning curve, leading to rejected insurance claims and a cash-flow crisis. In response, CMS instituted the 1-year grace period, which it calls a year of "ICD-10 flexibilities." The agency said that its contractors would process, and not audit, FFS claims as long as they included a valid ICD-10 code from the right family, as in H66 for suppurative otitis media, or S62 for hand and wrist fractures.

However, these three-character categories are not valid codes in and of themselves that physicians can submit, CMS said in a question-and-answer memo on ICD-10 flexibilities that it issued together with the American Medical Association last week.

This flexibility policy is so generous that it even overlooks outright errors as long as they're committed in the right code family, according to the joint statement. It cited the example of a patient with a diagnosis of G43.711 — chronic migraine without an aura, intractable, with status migrainosus. If a physician submitted a claim with a code that was slightly off — such as G43.719, for chronic migraine without an aura, intractable, without status migrainosus — it would not trigger an audit because the incorrect code belonged to the right family, G43 for migraine.

This waiver also plays out for coding Hodgkin's lymphoma during the ICD-10 grace period. There are codes for a subtype called nodular lymphocyte predominant in an unspecified site (C81.00), in the intra-abdominal lymph nodes (C81.03), in the spleen (C81.07), and in seven other locations. And there are codes for other types of this cancer — such as nodular sclerosis classical and lymphocyte-rich classical — in different locations. Using any of them, said CMS, would not damn a Medicare claim. As of October 1, though, physicians need to pick the exact code for Hodgkin's lymphoma as warranted by the chart for their claims to pass muster.

ICD-10 codes for Hodgkin's lymphoma illustrates how physicians have been able to safely use unspecified codes during the grace period. To cover any diagnosis in this broad category, physicians who want to make coding easier can choose the catch-all C81.90 for Hodgkin's lymphoma, unspecified type, unspecified site. But again, on October 1, such catch-alls could catch hell if the record supports, say, a C81.07.

The same goes for wrist and hand injuries and their codes, which include two catch-alls. One is S62.90XA for a closed fracture of an unspecified bone in an unspecified hand in the first encounter. The other, S62.90XB, is identical except it applies to open fractures.

Now back to that case of suppurative otitis media, which offers a coding catch-all of H66.40. The codes for this condition allow physicians to identify whether it is the right ear, left ear, or both. Drilling down deeper, the code H66.001 indicates that it's an acute case without spontaneous rupture of the ear drum in the right ear. There's more than 30 other possible codes to choose from, challenging physicians to code as specifically as their documentation permits, and, more importantly, to document patient care as thoroughly as possible.

But first things first, said Bernard Pfeifer, MD, who sits on the coding and reimbursement committee of the American Academy of Orthopaedic Surgeons.

"The most important thing is what you do for your patient," Dr Pfeifer told Medscape Medical News. "The second most important thing is documenting what you do. The third most important thing is sending a bill out the door that gets you paid for your work."

"Physicians Didn't Go to Medical School to Learn How to Code"

Laurie Johnson, an ICD-10 trainer with the healthcare consulting firm Panacea Healthcare Solutions, said that the 1-year grace period was designed to help physicians get up to speed on correct diagnostic coding, not coast along using unspecified or otherwise incorrect codes. "I've encouraged them to code to the highest level of specificity possible," Johnson told Medscape Medical News.

Will the end of the grace period result in a wave of claims getting rejected by Medicare and private insurers as they stop looking the other way at ICD-10 miscoding? "I don't have a sense for that," said Johnson. "We'll have to wait and see."

She sympathizes with physicians confronted by the complexity of the new diagnostic codes. "Physicians didn't go to medical school to learn how to code," said Johnson, national correspondent for a weekly podcast on ICD-10 issues available on the news website ICD10monitor.com. She advocates letting credentialed coders do that job.

"I would rather have physicians treat patients," she said.

Follow Robert Lowes on Twitter @LowesRobert

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