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 is 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 ICD-10 or the significant changes to some ophthalmology diagnosis codes for 2017. The problem is going to be with the physician’s clinical documentation being sufficiently specific to select the appropriate code.
New, Deleted, and Changed Codes in 2017 ICD-10
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. To review the full list click on the following link. (ICD-10 List)
For illustrative purposes only, NCI selected two (2) diagnoses to reflect some of the changes ophthalmologists will see in 2017 ICD-10.
For example, the following ICD-10 codes have been deleted:
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
Physicians are now required to indicate the condition present in each eye:
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
The following coding instructions for glaucoma are included in the ICD-10 Guidelines
Diseases of the Eye and Adnexa (H00-H59)
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.
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.
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.
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 7th 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 7th 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 7th characters is to be assigned to code E11.37
1 = right eye
2 = left eye
3 = bilateral
9 = unspecified eye
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).
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.
• 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, abnormal test results, or other reason for the visit.
- 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. 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.
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.
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.
New! Age-Related Macular Degeneration Decision Tree
Revised! Diabetes Decision Tree
New! Vein Occlusion Decision Tree
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.
Question 23 When will the Medicare ICD-10 flexibilities expire?
Answer 23 The ICD-10 flexibilities expire on October 1, 2016.
Question 24 Will the ICD-10 flexibilities be extended beyond October 1, 2016?
Answer 24 CMS will not extend ICD-10 flexibilities beyond October 1, 2016. There will be no additional flexibility guidance.
Question 25 Is Medicare going to phase in the requirement to code to the highest level of specificity?
Answer 25 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 How do I get ready for the end of flexibilities?
Answer 26 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 Will unspecified codes be allowed once ICD-10 flexibilities expire?
Answer 27 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?
Answer 28 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.
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?
Answer 30 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.
Question 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?
Answer 33 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.