ICD-10 & Friends Sampler Resistance is futile Disclaimer This presentation is brought to you by Harry Goldsmith, DPM who is solely responsible for its content and delivery so don’t complain to or blame the American Podiatric Medicine Association for any demonstrated insensitivity, poor judgment, unfunny jokes, puns that aren’t punny, or lack of taste. * Always check with individual payers for their policies and guidelines Disclaimer The APMA Coding Resource Center is wholly owned and operated by the American Podiatric Medical Association. It is partially sponsored by Mertz North America. Part of the proceeds from each subscription is contributed to the APMA Educational Foundation Student Scholarship Fund. I do not receive any payment for promoting the CRC. Nor am I on scholarship… APMA Coding Resource Center www.apmacodingrc.org “59” Modifier Question Distinct Procedural Service • Modifier of last resort (i.e., use more specific modifiers if you can) • Identifies the procedure(s) as being distinct and separate from other procedures performed the same date “59” Modifier • This modifier unbundles CCI or other global bundling edits • The documentation must clearly evidence that the procedure or service was comprehensive, and not a component of another billed procedure Introducing January 1, 2015 XE - Separate Encounter, a service that is distinct because it occurred during a separate encounter. XS - Separate structure, a service that is distinct because it was performed on a separate organ/structure. XP - Separate Practitioner, a service that is distinct because it was performed by a different practitioner. XU - Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service. The ICD-10 “Why” Question ICD-9 has been used HIPAA regulations by the US for 35 years mandate the move to ICD-9 has outgrown its ICD-10 intended level of CMS announced it will specificity no longer support ICD-9 ICD-9 cannot The rest of the world is reasonably moving toward ICD-11 accommodate new codes The “Why” Question is no longer important Timing Less than 1 year away (again) Transitioning Your Members 1. Someone in the office/group needs to be designated the ICD-10 “project manager” 2. Primary vendors need to be contacted and asked how ready they are for ICD-10 3. Practice major payers need to be contacted about signing up for ICD-10 “testing” Transitioning Your Members 4. Your state should plan to put on (or contacting APMA for) ICD-10 workshops and learning sessions 5. Members need to begin (and complete) the crosswalking of existing ICD-9 codes used by the practice to ICD-10 codes Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 #1 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Abrasion ankle, left What’s the main term? Crosswalking ICD-9 to ICD-10 Abrasion ankle, left What’s the main term? Crosswalking ICD-9 to ICD-10 1. Go to the ICD-10 Index to “Diseases & Injuries” Crosswalking ICD-9 to ICD-10 1. Go to the ICD-10 Index to “Diseases & Injuries” 2. Look under “A” for “Abrasion” Crosswalking ICD-9 to ICD-10 1. Search for “Abrasion” Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 The Hyphen (or Dash) Educational Moment A hyphen at the end of an ICD-10 indicates that additional characters are required You will only see the hyphen on a code in the alphabetic index Crosswalking ICD-9 to ICD-10 Underscore = Hyperlink Crosswalking ICD-9 to ICD-10 S90.51 Crosswalking ICD-9 to ICD-10 S90.51 Crosswalking ICD-9 to ICD-10 category S90.51 subcategory subcategory subcategory Let the abrasion be on the right ankle Crosswalking ICD-9 to ICD-10 S90.511 Let the abrasion be on the right ankle Crosswalking ICD-9 to ICD-10 S90.511 Let the abrasion be on the right ankle Crosswalking ICD-9 to ICD-10 5+ 6+ 7+ The “additional character indicator” box located in front of a code is a “hint” that you need one or more additional characters at the end to get to the code of highest specificity Crosswalking ICD-9 to ICD-10 S90.511 Scrollup Crosswalking ICD-9 to ICD-10 S90.511 Crosswalking ICD-9 to ICD-10 S90.511 “A” – Initial Encounter S90.511A Don’t think “encounter” Think “episode of care” or “active treatment” or “phase of treatment” “A” – Initial Encounter S90.511A Used while the patient is receiving active treatment for a condition. “A” – Initial Encounter “Used while the patient is receiving active treatment for a condition.” How is “active treatment” defined? “A” – Initial Encounter S90.511A Examples of active treatment are: surgical treatment, emergency department encounter, &evaluation and treatment by a new physician. “A” – Initial Encounter S90.511A Examples of active treatment are: surgical treatment, emergency department encounter, & evaluation and continued treatment by the same or a different physician. Huh? “A” – Initial Encounter There can only be one “initial” episode of care per doctor per condition So, what is an initial episode of care? In a hospital, an episode of care is from admission to discharge “A” – Initial Encounter Can more than one provider code a 7th character “A” during an episode of care? A patient goes to the emergency department and the ED physician sees the patient, orders x-rays, has both an infectious disease specialist and a foot and ankle specialist do a consult in the ED, how many physicians get “A”s? …at least 4… “D” – Subsequent Encounter S90.511D “D” – Subsequent Encounter “Used after the patient has received active treatment for the condition during the healing or recovery phase.” When does active treatment end? How do you define “healing phase”? “D” – Subsequent Encounter S90.511D Examples of subsequent care are: cast change or removal, an x-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following treatment of the injury. “A” & “D” – A Fly in the Ointment Disclaimer – Best Current Interpretation 1. If you see a patient in the ED for the first time, it’s an “A” 2. If the patient is admitted and you round 3 times during the admission, it’s an “A” each time 3. If the patient is discharged from the hospital to your care and you see them in the office, it’s a “D” 4. If you reappoint and see the patient for follow-up care, it’s a “D” “A” & “D” – A Fly in the Ointment Disclaimer – Best Current Interpretation 5. If the patient was seen by a primary care physician in their office for an injury and then was referred to you for follow-up, the 1st time you see that patient for that condition, it’s an “A” 6. If there is no referral, but instead a patient calls your office and tells you they just twisted their ankle. You tell the patient to come to your office and you see them for the 1st time for that condition, it’s an “A” 7. When the patient returns for follow-up care, it’s a “D” “A” & “D” – A Fly in the Ointment Unanswered Questions 1. The “initial encounter” description is definite for “physician”, what about NPs, PAs, PTs, OTs, etc.? 2. If you belong to a podiatry supergroup (7 docs), and one of your partner’s patients with an established condition sees you because you are available, is that an “A” or “D” for you? 3. What if you happened to be a podiatrist in a small orthopedic group (65 docs), same scenario, is that an “A” or “D” for you? 4. Why did CDC/CMS make this so confusing? “S” – Sequela Sequela Some Other Time Crosswalking ICD-9 to ICD-10 ICD-9 916.0 crosswalks to ICD-10 S90.511A (initial encounter) Tada Crosswalking ICD-9 to ICD-10 #2 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 ICD-9 355.6 crosswalks to ICD-10 G57.62 (neuroma, left “lower limb”) Tada Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 #3 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 ICD-9 728.71 crosswalks to ICD-10 M72.2 Tada Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 #4 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Crosswalking ICD-9 to ICD-10 Tada ICD-10 Educational Moment “Not coded here” - mutually exclusive; can never occur at the same site along with the primary condition ICD-10 Educational Moment New Terms: Excludes1 Excludes2 Excludes1 “Not coded here” - mutually exclusive; can never occur at the same site along with the primary condition Excludes1 “Not coded here” - mutually exclusive; can never occur at the same site along with the primary condition Excludes2 Degenerative joint disease 1st metatarsal- phalangeal joint “Not included here” – the excluded condition is not part of the condition represented in the primary code.