CODING AND REIMBURSEMENT Volume 14 • No. 3 October 2016
Pennsylvania Ophthalmology News
Big Changes in ICD-10 for Ophthalmology By Joy Newby, LPN, CPC, Newby Consulting, Inc.
To assist physicians in ICD-10 implementation, the Centers for Medicare & Medicaid Services (CMS) granted flexibility for one year. At that time, CMS reminded physicians that diagnosis coding to the correct level of specificity was the goal for all claims; however, for 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family was submitted, Medicare fee-for-service processed and did not edit valid ICD-10 codes unless specific coding was required by a National Coverage Decision (NCD) or Local Coverage Decision (LCD). ICD-10 flexibility ended for dates of service on and after October 1, 2016.
NCI Comment: We believe the problem in reporting more specific codes is not due to the change to ICD10 or the significant changes to some ophthalmology
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diagnosis codes for 2017. The problem is going to be with the physician’s clinical documentation being sufficiently specific to select the appropriate code.
CODING AND REIMBURSEMENT
New, Deleted, and Changed Codes for 2017 In addition to specificity requirements, ICD-10 has been updated for the first time in several years. As you review the 2017 ICD-10 manual, you will find approximately 5500 changes. Ophthalmology will notice many new, deleted, and changed codes. A list of the 2017 changes is posted on PAO’s website at www.paeyemds.org under “Coding & Reimbursement” in the Members Only section.
The following coding instructions for glaucoma are included in the ICD-10 Guidelines.
a. Glaucoma 1) Assigning Glaucoma Codes Assign as many codes from category H40, Glaucoma, as needed to identify the type of glaucoma, the affected eye, and the glaucoma stage.
For example, the following ICD-10 codes have been deleted:
2) Bilateral glaucoma with same type and stage When a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and there is a code for bilateral glaucoma, report only the code for the type of glaucoma, bilateral, with the seventh character for the stage.
H40.11X0
Deleted Primary open-angle glaucoma, stage unspecified
H40.11X1
Deleted Primary open-angle glaucoma, mild stage
H40.11X2
Deleted Primary open-angle glaucoma, moderate stage
H40.11X3
Deleted Primary open-angle glaucoma, severe stage
H40.11X4
Deleted Primary open-angle glaucoma, indeterminate stage
For illustrative purposes only, NCI selected two (2) diagnoses to reflect some of the changes ophthalmologists will see in 2017 ICD-10.
Glaucoma
Physicians are now required to indicate the condition present in each eye:
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Diseases of the Eye and Adnexa (H00-H59)
H40.1110
Primary open-angle glaucoma, right eye, stage unspecified
H40.1111
Primary open-angle glaucoma, right eye, mild stage
H40.1112
Primary open-angle glaucoma, right eye, moderate stage
H40.1113
Primary open-angle glaucoma, right eye, severe stage
H40.1114
Primary open-angle glaucoma, right eye, indeterminate stage
H40.112
Primary open-angle glaucoma, left eye
H40.1120
Primary open-angle glaucoma, left eye, stage unspecified
H40.1121
Primary open-angle glaucoma, left eye, mild stage
H40.1122
Primary open-angle glaucoma, left eye, moderate stage
H40.1123
Primary open-angle glaucoma, left eye, severe stage
H40.1124
Primary open-angle glaucoma, left eye, indeterminate stage
H40.113
Primary open-angle glaucoma, bilateral
H40.1130
Primary open-angle glaucoma, bilateral, stage unspecified
H40.1131
Primary open-angle glaucoma, bilateral, mild stage
H40.1132
Primary open-angle glaucoma, bilateral, moderate stage
H40.1133
Primary open-angle glaucoma, bilateral, severe stage
H40.1134
Primary open-angle glaucoma, bilateral, indeterminate stage
H40.119
Primary open-angle glaucoma, unspecified eye
H40.1190
Primary open-angle glaucoma, unspecified eye, stage unspecified
H40.1191
Primary open-angle glaucoma, unspecified eye, mild stage
H40.1192
Primary open-angle glaucoma, unspecified eye, moderate stage
H40.1193
Primary open-angle glaucoma, unspecified eye, severe stage
H40.1194
Primary open-angle glaucoma, unspecified eye, indeterminate stage
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When a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and the classification does not provide a code for bilateral glaucoma (i.e. subcategories H40.10, H40.11 and H40.20) report only one code for the type of glaucoma with the appropriate seventh character for the stage.
3) Bilateral glaucoma stage with different types or stages When a patient has bilateral glaucoma and each eye is documented as having a different type or stage, and the classification distinguishes laterality, assign the appropriate code for each eye rather than the code for bilateral glaucoma. 4) Patient admitted with glaucoma and stage evolves during the admission If a patient is admitted with glaucoma and the stage progresses during the admission, assign the code for highest stage documented. [In this scenario, admitted refers to the patient being followed for glaucoma and during the visit, the physician notes the glaucoma stage has progressed. Physicians are instructed to use patient’s current diagnosis.] 5) Indeterminate stage glaucoma Assignment of the seventh character “4” for “indeterminate stage” should be based on the clinical documentation. The seventh character “4” is used for glaucoma diagnoses whose stage cannot be clinically determined. [For example, the patient’s visual field has not been performed or has not been interpreted by the physician.] This seventh character should not be confused with the seventh character “0”, unspecified, which should be assigned when there is no documentation regarding the stage of the glaucoma. [Emphasis Added]
CODING AND REIMBURSEMENT Diabetes Mellitus With implementation of 2017 ICD-10, coding diabetic patients with ophthalmic manifestations frequently requires a seventh digit to indicate which eye is involved. For example, E11.34 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy One of the following seventh characters is to be assigned to codes in subcategory E11.34 to designate laterality of the disease: 1 = right eye 2 = left eye 3 = bilateral 9 = unspecified eye E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy, with macular edema E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy, without macular edema You will also note that ICD-10 codes E11.35 used for Type 2 diabetes mellitus with proliferative diabetic retinopathy (E11.351 = with macular edema; E35.359 = without edema) has been greatly expanded. E11.35 Type 2 diabetes mellitus with proliferative diabetic retinopathy One of the following seventh characters is to be assigned to code E11.35 1 = right eye 2 = left eye 3 = bilateral 9 = unspecified eye E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema E11.352 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E11.353 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E11.354 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E11.355 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema In addition, there are new codes for Type 2 diabetes with diabetic macular edema, resolved following treatment. E11.37 Type 2 Diabetes mellitus with diabetic macular edema, resolved following treatment One of the following seventh characters is to be assigned to code E11.37 1 = right eye 2 = left eye 3 = bilateral 9 = unspecified eye
Secondary Diabetes We are frequently asked when to use the codes for secondary diabetes. According to the ICD-10-CM Guidelines: Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, or poisoning).
AAOE ICD-10 Decision Trees and Guides The AAOE has updated existing decision trees and guides and has created new ones to assist ophthalmologists in managing the expiration of flexibility as well as incorporating the new, deleted, and changed ICD-10 codes into your practice. The information is available on the AAOE website at http://www. aao.org/practice-management/coding/ ICD-10-cm/resources.
Subspecialty ICD-10 Decision Trees and Guides AAOE physician decision trees and quick-reference guides have been updated to include the new and revised ICD-10 changes effective Oct. 1, 2016. These easy-to-print resources are a great educational tool for physicians and staff.
Decision Trees
• New! Age-Related Macular Degeneration Decision Tree • Revised! Diabetes Decision Tree • New! Vein Occlusion Decision Tree
Guides • • • • • •
Cornea Guide Glaucoma Guide Neuro-Ophthalmology Guide Oculofacial Guide Pediatric Strabismus Retina Guide
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CODING AND REIMBURSEMENT
Back to the Basics Let’s refresh our memory regarding the sequencing of diagnosis codes. The ICD-10 guidelines include the following instructions (Not All-Inclusive): • For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. • List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases, the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. [Emphasis Added] • Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/ visit, such as symptoms, signs,
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abnormal test results, or other reason for the visit. [Emphasis Added] • Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (codes R00-R99) contain many, but not all codes for symptoms. • Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) • Code all documented conditions that coexist at the time of the encounter/ visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. [Emphasis Added] However, history codes (categories Z80- Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
• For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive. • The subcategories for encounters for general medical examinations, Z00.0-, provide codes for with and without abnormal findings. Should a general medical examination result in an abnormal finding, the code for general medical examination with abnormal finding should be assigned as the first-listed diagnosis. An examination with abnormal findings refers to a condition/diagnosis that is newly identified or a change in severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physical examination. A secondary code for the abnormal finding should also be coded. [Emphasis Added]
CODING AND REIMBURSEMENT CMS FAQs – ICD-10-CM The CMS website provides several resources related to ICD-10-CM. We have selected the following FAQs related to the end of the flexibility period. https://www.cms.gov/Medicare/Coding/ICD-10/Clarifying-Questions-and-AnswersRelated-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf Question 23 Answer 23
When will the Medicare ICD-10 flexibilities expire? The ICD-10 flexibilities expire on October 1, 2016.
Question 24 Answer 24
Will the ICD-10 flexibilities be extended beyond October 1, 2016? CMS will not extend ICD-10 flexibilities beyond October 1, 2016. There will be no additional flexibility guidance.
Question 25 Answer 25
Is Medicare going to phase in the requirement to code to the highest level of specificity? No, providers should already be coding to the highest level of specificity. ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud. These ICD-10 medical review flexibilities will end on October 1, 2016.
As of October 1, 2016, providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines.
Question 26 Answer 26
How do I get ready for the end of flexibilities? Avoid unspecified ICD-10 codes whenever documentation supports a more detailed code. Check the coding on each claim to make sure that it aligns with the clinical documentation.
A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website. The codes are listed in tabular order to reflect the ICD-10-CM code book.
Question 27 Answer 27
Will unspecified codes be allowed once ICD-10 flexibilities expire? Yes. In ICD-10-CM, unspecified codes have acceptable, even necessary, uses. Information about unspecified codes, including an MLN Matters article and videos, can be found on the CMS website. 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).
Question 28
What level of ICD-10 code specificity is required so that my claims will not be rejected? How can I ensure my claims will be approved/paid? Even with the ICD-10 flexibilities guidance established by the CMS-AMA Agreement, as of October 1, 2015, a valid ICD-10 code has been required on all claims billed under the Medicare Fee-for-Service Part B physician fee schedule.
Answer 28
A complete list of the 2017 ICD-10-CM valid codes and code titles is posted on the CMS website. The codes are listed in tabular order to reflect the ICD-10-CM code book. Also available is 2017 ICD-10-CM, the updated diagnosis code set for services provided on or after October 1, 2016.
You should always code to accurately reflect the clinical documentation, and in as much specificity as possible. ICD-10 was implemented in part because of the higher degree of detail that it allows to describe the services you provide.
Avoid unspecified ICD-10 codes when documentation backs up a more detailed code. Check the coding on each claim to make sure that it aligns with the clinical documentation.
Question 30
How does the end of the ICD-10 flexibilities affect audits that begin after October 1, 2016, but are for claims with dates of service before October 1, 2016? Beginning October 1, 2016, all CMS review contractors are able to use coding specificity as the reason for an audit for a denial of a reviewed claim to the same extent that they did prior to October 1, 2015. Review contractors will notify providers of coding issues they identify during review and of steps needed to correct those issues to the same extent that they did prior to October 1, 2015. The provider community should code claims to the degree of specificity supported by the encounter and the medical documentation.
Answer 30
Question 33 Answer 33
With the expiration of the ICD-10 flexibilities, is Medicare also prepared to handle and process claims using the new ICD-10 codes that become effective October 1, 2016? As demonstrated by the successful ICD-10 transition, CMS is well equipped to handle changes to codes and to processes, and we do not anticipate any delays. The annual update to codes is not a new process. Codes were regularly updated on an annual basis until a freeze was established to assist providers and health plans to prepare for ICD-10.
As with previous annual updates to codes, providers should: 1) determine which codes affect their practices, and 2) focus on clinical concepts behind new codes. While this year’s update includes many new codes, the new clinical concepts are minimal.
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Update on Provider Supplier Revalidation Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers and suppliers to resubmit and recertify their Medicare enrollment information under new enrollment screening criteria. CMS completed its initial round of revalidations (cycle 1) in March 2015 and in March 2016, resumed regular revalidation cycles (cycle 2) with several process improvements. Cycle 2 revalidation applies to those providers and suppliers that are currently and actively enrolled with Medicare. CMS has established due dates by which a provider or supplier’s revalidation application must reach the Medicare Administrative Contractor (MAC) in order for them to
remain in compliance with Medicare’s provider enrollment requirements. Due dates are posted on the CMS Medicare Revalidation Lookup Tool at: http://go.cms. gov/MedicareRevalidation. The Medicare Revalidation List was last refreshed September 01, 2016 (due dates March 01, 2016- March 31, 2017). Reminder: If a provider or supplier fails to submit the revalidation application by the due date, or if the provider or supplier provides additional requested information after the due date (including an allotted time period for US or other mail receipt), the provider enrollment record will be deactivated. Deactivated providers and
suppliers will be required to submit a full and complete application in order to reestablish their provider enrollment record and related Medicare billing privileges. An interruption in billing will occur during the period of deactivation, resulting in a gap in coverage. Retroactive billing privileges back to the period of deactivation will not be granted. Services provided to Medicare beneficiaries during the period between deactivation and reactivation are the provider’s liability. Any questions or concerns regarding this educational letter should be directed to Andrea King, Novitas Provider Outreach and Education, at: andrea.king@novitas-solutions. com or 717-526-6392.