CME Cindy Hughes, CPC, CFPC ICD-10: Major Differences for Five Common Diagnoses Test your knowledge of ICD-10 coding E11.65, Type 2 diabetes mellitus with hyperglycemia and documentation requirements for five diagnoses you’re likely to encounter in family medicine. he time has come. Are you ready for the Oct. 1 A. Diagnosis codes support the medical necessity transition to ICD-10 diagnosis coding? If you are of services provided. not sure, you are not alone. Many elements of B. Diagnosis codes support claims payment. this transition have depended on your software C. Diagnosis data is increasingly used to evaluate T vendors, clearinghouses, payers, and staff, but there is one cost and quality of care. thing you can control: your documentation of the informa- D. Diagnosis data is used to influence public tion necessary to support the diagnosis codes you choose to health policy. bill. Your documentation probably does not need a major E. All of the above. overhaul, but you will need to be more specific and detailed Answer: The diagnosis codes reported on physician in certain areas. In this article, we will look at the documen- claims must be supported not only to facilitate payment tation elements required to support ICD-10 code selection, but also because they become the data upon which deci- focusing on five common conditions in family medicine. sions beyond claims payment are made. The correct answer Quizzes will test your knowledge throughout the article. to the above question, then, is E, all of the above. Documentation that supports specific diagnosis coding also may alleviate burdensome medical record requests First, why should you care? from third parties. Take for instance the following state- The increased specificity required in your documentation ment a physician forwarded to me from a claims admin- and coding under ICD-10 may seem unnecessarily bur- istrator regarding medical record requests to support risk densome. However, diagnosis coding has a wider impact adjustment: “ICD-9-CM (or its successor ICD-10-CM) than you might immediately recognize. diagnosis codes determine a patient’s risk score. The more Question: In which of the following ways does diagno- diagnosis detail submitted with claims and encounters, the sis coding affect physician practices and patient care? less likelihood that [insurer name redacted] will need to About the Author Cindy Hughes is an independent coding consultant based in El Dorado, Kan., and a contributing editor to Family Practice Management. Author disclosure: no relevant financial affiliations disclosed. Downloaded from the Family Practice Management website at www.aafp.org/fpm. Copyright © 2015 American Academy of Family Physicians. For theSeptember/October private, noncommercial 2015 | usewww.aafp.org/fpm of one individual | FAMILY user of PRACTICE the website. MANAGEMENT | 15 © CHRISTINE SCHNEIDER CHRISTINE © All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. request and audit medical records.” In other not support a more specific diagnosis. The words, if your documentation supports the guidelines state, “It would be inappropriate to level of service coded and the selected diagnosis select a specific code that is not supported by codes specifically identify the nature of your the medical record documentation or conduct patient’s condition, you are less likely to receive medically unnecessary diagnostic testing in a request for your medical record. If a request order to determine a more specific code.” is made, your documentation will support both Other important documentation guidelines Your documenta- the service provided and why it was provided. include the following: tion may not need an overhaul for • List first a disease and then associated manifestations, ICD-10, but it What to report will need to be • Link sequelae (late or residual conditions) more specific and Before we review common diagnoses, it is to the history of an injury or past medical detailed in certain important to know when codes should and condition, areas. should not be reported for a condition. • Report personal or family history codes Question: According to the official guide- when the history affects care or influences lines for ICD-10, which of the following con- treatment. ditions should be reported? For asthma, be A. All conditions listed in the problem list. Five common diagnoses sure to document B. Only conditions with confirmed and the classification differential diagnoses. With so many diagnoses in primary care, it (e.g., intermittent) C. All conditions that require or affect makes sense to focus your ICD-10 education and the status (e.g., with exacerbation). patient care or treatment at the time of the efforts on those that are common in your spe- encounter. cialty. The National Center for Health Statis- D. Only the condition related to the chief tics provides this data.1 complaint. Question: Which condition is the top If you don’t docu- E. Conditions that are probable. reason for office or other outpatient visits to ment these details, Answer: The ICD-10 guidelines (like family physicians? you must report ICD-9) specify that physicians should not A. Diabetes. code J45.909, report the following: B. Hypertension. unspecified and • Conditions documented as probable, C. Otitis media. uncomplicated likely, or to be ruled-out (rules differ for D. Asthma. asthma. facilities), E. Well-child examinations. • Codes for symptoms that are integral to Answer: All of the above conditions are an established diagnosis, near the top of the list for family medicine, but • Conditions that are no longer present, for the number one diagnosis, you’ll have to • Conditions that did not affect manage- read on. Let’s take a look at five commonly ment or treatment at the current encounter. reported diagnoses and their documentation Therefore, the answer to the question is requirements under ICD-10. C. All conditions that require or affect patient care or treatment at the time of the encoun- Number five: asthma ter should be reported. Physi- Asthma classification in ICD-10 mirrors J45.41, Moderate cians should the guidelines from the National Asthma persistent asthma with list first the Education and Prevention Program, which acute exacerbation condition that is differs from ICD-9.2 chiefly respon- Question: Which of the following is not sible for the services provided and code what an option for the classification of asthma in is known at the time of the encounter. ICD-10? This instruction to code what is known at A. Intrinsic. the time of the encounter is important. Based B. Mild intermittent. on this guideline, physicians should report C. Mild persistent. unspecified codes such as J12.9, unspeci- D. Moderate persistent. fied viral pneumonia, when the information E. Severe persistent. known at the time of the encounter does Answer: All of the above classifications are 16 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | September/October 2015 ICD-10 COMMON DX options in ICD-10 except A, intrinsic. That in a disease classified elsewhere) would sup- was the old terminology used in ICD-9. port code H66.93 (otitis media, unspecified, In addition to documenting the asthma bilateral). But better documentation, such classification, physicians should document as acute recurrent the status of the condition at each encoun- bilateral suppurative H65.01 Acute serous ter. “Table one: Documentation elements for otitis media without asthma” (page 18) includes the codes for each spontaneous rupture otitis media, right ear asthma classification by status. of the ear drum If you were to document asthma without (H66.006), may help to identify the need for specifying the classification or status, that higher levels of medical decision-making or would be reported with code J45.909, unspeci- additional services. (See “Table two: Docu- fied and uncomplicated asthma. However, mentation elements for otitis media,” page 18.) consider the implications of reporting J45.909 for a patient who is not compliant with control Number three: diabetes medications, is seen for an acute exacerbation, and requires a revised care plan. This code not Key documentation elements for diabetes are only fails to identify the nature of the patient the type of diabetes, manifestations of the dis- presentation but also fails to convey the assess- ease, and use of insulin (not necessary for type ment of the asthma status and the complicat- 1 diabetes). “Table three: Documentation ele- ing factor of noncompliance. Documenting a ments for diabetes” (page 18) illustrates the bit more detail – moderate persistent asthma requirements. with exacerbation, J45.41 – better conveys the Question: Which of the following docu- nature of the encounter. Code Z91.14 could mentation elements would be required to be added to specify the patient’s poor compli- accurately code an encounter with a patient ance with control medication and explain the who has diabetes, loss of protective sensation, patient management complications. a foot ulcer, and an elevated A1C result? A. Type of diabetes. When document- ing otitis media, B. Location of the ulcer. Number four: otitis media don’t forget the C. Related conditions (manifestations). new requirement Both ICD-9 and ICD-10 provide codes to spe- D. Condition status/characteristics (e.g., to specify lateral- cifically identify otitis media as acute or chronic uncontrolled). ity (right, left, or and as serous, allergic, or suppurative. Despite E. All of the above. bilateral). the availability