ICD-10 Changes Everything!

Any entity, hospital, ASC, Durable Medical Equipment Supplier, pharmacy, physician submitting a claim to a third party payer, must comply with the new code set, ICD-10-CM to define the patient’s diagnosis (es) necessitating the service(s) rendered. The ICD-10-CM code set is radically different than ICD-9 with thousands of new diagnosis codes that are much more specific than they used to be. Diagnostic coding is the cornerstone of medical necessity, and payers require each patient’s claim to be as specific as possible, listing all relevant diagnosis(es) that impact the reason for the medical encounter. Otherwise, the claim will be returned for additional information, or it may be simply denied. Furthermore, no longer can physicians and/or facilities rely on unspecified codes to describe a patient’s condition. Due to the degree of specificity provided under the ICD-10 code set, claims will be denied or returned unless there is no other coding option besides the unlisted or unspecified diagnosis code.

For example, under ICD-9-CM, intracerebral hemorrhage was described with only one diagnostic code, 431, intracerebral hemorrhage. Under ICD-10-CM, intracerebral hemorrhage is described by 9 diagnosis codes, all describing the nuances and location of nontraumatic intracerebral hemorrhage (in hemisphere, subcortical, cortical, unspecified, brain stem, cerebellum, intraventricular, multiple, other or nontraumatic intracranial hemorrhage).

Why does this matter to medical device manufacturers? If your company manufactured a product used in the treatment of intravascular hemorrhage, such as microcoil, your customers may be asking you how the product and procedure for which it is used is coded. You, as the manufacturer, will want to provide accurate information based on the new ICD-10-CM code set. Ultimately, the provider is responsible for their own coding choices, but it is very common for medical device manufacturers to provide suggestions on correct coding options for your customers.

Who has the final say on diagnostic coding?  Under the ICD-10-CM coding system, coding is based on the documentation provided by the attending  physician and recorded in the patient’s medical record. Coders cannot assume anything, and are strictly held to the rule that if a diagnosis or procedure is not specified, it was not present or was not done. If the documentation does not support use of a diagnostic or procedure code, revenues may be lost or seriously compromised. Therefore, it is more important than ever that physicians understand the expansiveness of ICD-10-CM codes, and dictate patient chart notes based on the new coding guidelines, avoiding whenever possible an unspecified or NOS code.

Procedures versus Diagnostic: ICD-10-PCS codes are another important component of ICD-10. ICD-10-PCS codes describe procedures performed exclusively in the inpatient hospital setting. Physicians, hospital outpatient departments, and Ambulatory Surgery Centers do not use ICD-10-PCS codes (instead, these procedures are described under the CPT code set to describe procedures performed). Like ICD-10-CM diagnostic codes, hospital coders rely on the patient’s medical record to select ICD-10-PCS codes. If you are a manufacturer of products used in the inpatient setting, you must provide coding instruction to your customers (physicians and hospitals) that will enable them to quickly identify the appropriate code(s). Physician documentation, again, is critical and will mandate the final selection of hospital inpatient procedure code selections.

Reimbursement Principles can assist you with updating or creating new reimbursement collateral materials. Contact us for additional information on ICD-10-CM/PCS codes.

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