ICD-10 PROS, TIPS and ICD 9 Comparison table

International Classification of Diseases (ICD-10)

ICD-10 was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in World Health Organization (WHO) Member States as from 1994. WHO's original intent for ICD was as a statistical tool for the international exchange of mortality data. A subsequent revision was expanded to accommodate data collection for morbidity statistics. On January 1, 1999 U.S. implemented for mortality statistics (death certificates). Actually is being used by the following countries for reimbursement or Case Mix;

• United Kingdom (1995)

• Nordic countries (Denmark, Finland, Iceland, Norway,

   Sweden) (1994 – 1997)

• France (1997)

• Australia (1998)

• Belgium (1999)

• Germany (2000)

• Canada (2001)

PROS

Right now, even with the less precise codes, the codes help drive research on the quality, cost, accessibility and outcomes of health services. They also help identify trends in care.

• Reimbursement – would enhance accurate payment for services rendered
• Quality – would facilitate evaluation of medical processes and outcomes
• Flexible enough to quickly incorporate emerging diagnoses and procedures
• Exact enough to identify diagnoses and procedures precisely
• Incorporates much greater specificity and clinical information, which results in
• Improved ability to measure health care services
• Increased sensitivity when refining grouping and reimbursement methodologies
• Enhanced ability to conduct public health surveillance
• Decreased need to include supporting documentation with claims
• Provides detailed information on procedures
• Ample space for capturing new technology and devices
• Logical structure with clear, consistent definitions

TIPS

It is complex. Compared with the 15,000 diagnostic codes in the current system there will now be 70,000. The number of codes for inpatient hospital procedures—now totaling in at 4,000—will spike to 72,000. Many of the codes will not be needed on a regular basis (like V97.33CD, which indicates you were sucked into a jet engine, and this is your subsequent visit to a doctor). The average medical office probably won’t need more than 40 to 50 ICD codes for diagnosis, by this time you should have selected the most used codes for your practice. You can also select the most appropriate codes by the population you serve. (Ex. High population with HBP, DM, etc.)

TIP # 1 Identify the most used codes for your practice.

TIP # 2 Look for specific codes/category within every ICD-10 sections.

TIP # 3 Start dual coding until you are familiar with the most used ICD-10 codes.

ICD-9 vs. ICD 10 section comparison table

ICD-10	ICD-9
Chapter I Certain infectious and parasitic diseases (A00-B99)	Codes 001–139: infectious and parasitic diseases
Chapter II Neoplasms (C00-D49)	Codes 140–239: neoplasms
Chapter III Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)	Codes 280–289: diseases of the blood and blood-forming organs
Chapter IV Endocrine, nutritional and metabolic diseases (E00-E90)	Codes 240–279: endocrine, nutritional and metabolic diseases, and immunity disorders
Chapter V Mental and behavioral disorders (F01-F99)	Codes 290–319: mental disorders
Chapter VI Diseases of the nervous system (G00-G99)	Codes 320–359: diseases of the nervous system
Chapter VII Diseases of the eye and adnexa (H00-H59)
Chapter VIII Diseases of the ear and mastoid process (H60-H95)
Chapter IX Diseases of the circulatory system (I00-I99)	Codes 390–459: diseases of the circulatory system
Chapter X Diseases of the respiratory system (J00-J99)	Codes 460–519: diseases of the respiratory system
Chapter XI Diseases of the digestive system (K00-K93)	Codes 520–579: diseases of the digestive system
Chapter XII Diseases of the skin and subcutaneous tissue (L00-L99)	Codes 680–709: diseases of the skin and subcutaneous tissue
Chapter XIII Diseases of the musculoskeletal system and connective tissue (M00-M99)	Codes 710–739: diseases of the musculoskeletal system and connective tissue
Chapter XIV Diseases of the genitourinary system (N00-N99)	Codes 580–629: diseases of the genitourinary system
Chapter XV Pregnancy, childbirth and the puerperium (O00-O99)	Codes 630–679: complications of pregnancy, childbirth, and the puerperium
Chapter XVI Certain conditions originating in the perinatal period (P00-P96)	Codes 760–779: certain conditions originating in the perinatal period
Chapter XVII Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)	Codes 740–759: congenital anomalies
Chapter XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)	Codes 780–799: symptoms, signs, and ill-defined conditions
Chapter XIX Injury, poisoning and certain other consequences of external causes (S00-T98)	Codes 800–999: injury and poisoning
Chapter XX External causes of morbidity and mortality (V01-Y99)	Codes E and V codes: external causes of injury and supplemental classification
Chapter XXI Factors influencing health status and contact with health services (Z00-Z99)
Chapter XXII Codes for special purposes
	Codes 360–389: diseases of the sense organs

ELIMINATING ERRORS ON ALLERGY TESTING & ALLERGY IMMUNOTHERAPY DOCUMENTATION

Coverage Indications, Limitations, and Documentation Requirements

Allergy testing is performed to determine a patient's immunologic sensitivity or reaction to particular allergens for the purpose of identifying the cause of the allergic state, and is based on findings during a complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient.

Allergy testing can be broadly subdivided into two methodologies:

A.         In vivo testing (skin tests): this testing correlates the performance and evaluation of selective cutaneous and mucous membrane tests with the patient’s history, physician examination, and other observations.

Testing Type	Description
Percutaneous testing (scratch, puncture, prick)	Intracutaneous (intradermal) testing are used to evaluate immunoglobulin E (IgE) mediated hypersensitivity to inhalants, foods, hymenoptera (e.g., bee venom), drugs and/or chemicals.
Patch testing	Is used to differentiate allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD).
Photo patch	Is used to evaluate unique allergies resulting from light exposure.
Photo tests	Performed for the evaluation of photosensitivity disorders.

B.         In vitro testing (blood serum analysis): immediate hypersensitivity testing by measurement of allergen-specific serum IgE (CPT code 86003). Special clinical situations in which specific IgE immunoassays may be appropriate are included in the following table.

 ** In vitro allergy testing is not covered on the situations explained on the table below, because it is considered not medically reasonable and necessary.

Covered Situations	Non Covered Situations
Patients with severe dermatographism, ichthyosis or generalized eczema	Patients with no contraindications to skin testing
Patients who cannot be safely withdrawn from medications that interfere with skin testing (such as long-acting antihistamines, tricyclic antidepressants)	Patients being treated successfully for allergies
Uncooperative patients with mental or physical impairments.	Patients with mild symptoms
Evaluation of cross-reactivity between insect venoms (e.g., fire ant, bee, wasp, yellow jacket, hornet)	Patients who have had negative skin testing for the allergy in question In vitro testing is covered when medically reasonable and necessary as a substitute for skin testing; it is not usually necessary in addition to skin testing.
As adjunctive laboratory testing for disease activity of allergic bronchopulmonary aspergillosis and certain parasitic diseases.
Patients at increased risk for anaphylactic response from skin testing based on clinical history (e.g., when an unusual allergen is not available as a licensed skin test extract), or who have a history of a previous systemic reaction to skin testing.
Patients in whom skin testing was equivocal/inconclusive and in vitro testing is required as a confirmatory test.

C.         Other testing types

ü  Qualitative multi-allergen screen (CPT code 86005) is a non-specific screening test that does not identify a specific antigen, and is not covered by most health insurance providers.

ü  The use of sublingual, intracutaneous, and subcutaneous provocative and neutralization testing and neutralization therapy for food allergies are excluded from Medicare and most health insurance providers coverage, because available evidence does not show that these tests and therapies are effective.

ü  Allergen-specific IgG and IgG subclasses measured by using immunoabsorption assays and IgG and IgG subclass antibody tests for food allergy/delayed food allergic symptoms or intolerance to specific foods (eg., CPT code 86001) are considered experimental and investigational, as there is insufficient evidence in the published peer-reviewed scientific literature to support the diagnostic value of these tests.

ü  Measurements of total IgE levels (CPT code 82785-Gammaglobulin [immunoglobulin]; IgE) are not appropriate in most general allergy testing which is performed to determine a patient’s immunologic sensitivity or reaction to particular allergens for the purpose of identifying the cause of the allergic state. It would not be expected that total serum IgE levels would be billed unless evidence exists for allergic bronchopulmonary Asperigillosis (ABPA), select immunodeficiencies, such as the syndrome of hyper-IgE, eczematous dermatitis, atopic dermatitis in children and recurrent pyogenic infections, or in the evaluation for omalizumab therapy.

Documentation Requirements

The allergy skin test form should provide enough information for other physicians and healthcare professionals to understand what tests were performed, how the tests were performed and to be able to interpret them.

Medical record documentation must include the following information, and be available upon request:

ü  A complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient.

ü  The medical necessity for performing the test.

ü  The test methodology used.

ü  Location of the test (e.g. back, arm, etc…)

ü  Instrument used (e.g. testing device, needle size, commercial kit, etc…)

ü  Time elapsed between application of the test and reading of the test

ü  The measurement (in mm) of reaction sizes of both wheal and erythema response (in vivo testing).

ü  Concentration, dilution and diluent used in testing

ü  The medical necessity for the use of in vitro testing if used, instead of in vivo methods.

ü  The quantitative result (in kIU/L) for specific IgE testing (in vitro testing).

ü  The interpretation of the test results and how the results of the test will be used in the patient’s plan of care.

All diagnostic tests must be ordered by the physician/nonphysician practitioner who is treating the patient.

Allergen Immunotherapy

Allergen immunotherapy (desensitization), also referred to as specific immunotherapy, is the subcutaneous introduction of increasing doses of allergens to which the patient is sensitive. Allergen immunotherapy is antigen-specific; thus the sensitivity of the patient must be known before formulating extracts for therapy.

This therapy is generally reserved for patients with significant relapsing, subacute to chronic symptoms, where the symptoms are likely caused by allergic pathology, and in situations where other means of conservative therapy (including avoidance) have failed to control the symptoms adequately, or avoidance of the relevant allergen (e.g., dust mites, pollen, mold) is impractical.

Coverage
Coverage for allergen immunotherapy will be provided for patients with allergic rhinitis, allergic conjunctivitis, asthma, or a previous anaphylactic reaction to a stinging/biting insect or other arthropod when all four of the following criteria are met:

(1) The patient must have significant exposure to an allergen

(2) The patient must have demonstrated a significant level of sensitivity to the allergen

(3) The pattern of symptoms must conform to the pattern of exposure

(4) Other means of conservative therapy (including avoidance) have failed to control the symptoms, or avoidance of the relevant antigen (e.g., dust mites, pollen, mold) is impractical.

Generally, the course of allergen immunotherapy, if successful, should be continued until the patient has been symptom-free or has had substantially reduced symptoms for 1 to 2 years and in most cases from 3 to 5 years. If no response has occurred after 1 year at maintenance dose, the patient’s sensitivities should be reviewed. All patients on immunotherapy should be encouraged to maintain environmental control and may have to use concomitant medication, such as antihistamines.

Documentation Requirements

Medical record documentation maintained by the treating physician must clearly document the medical necessity to initiate allergen immunotherapy and the continued need thereof. The documentation should include:

ü    A history and physical that documents the following: a complete allergic history and physical examination; correlation of symptoms; occurrence of symptoms; exposure profile; documentation of allergic sensitization by accepted means and where attempts at avoidance have proven unsuccessful (or the impracticality of avoidance exists); and a copy of the sensitivity results.

Immunotherapy antigens mixing logs including the following information;

ü    Antigen mixed on each vial

ü    Dilution

ü    Volume

ü    Units

Immunotherapy Injections documentation with the following information;

ü    Date

ü    Dosage

ü    Injection site

ü    Reaction

ü    Healthcare provider signature (who administer the injection)

ELIMINATING DOCUMENTATION ERRORS IMPROVE CODING AND BILLING !

 Source: Medicare Claims Processing Manual, Chapter 12, Section 50(e) and Medicare Local and National coverage determination.

How to eliminate anesthesia claims filing errors

The following information is to provide awareness and clarification to providers and billers of Anesthesia services to eliminate claim filing errors.

In keeping with the American Society of Anesthesiologists’ standards for monitoring, MAC should be provided by qualified anesthesia personnel in accordance with individual state licensure. These individuals must be continuously present to monitor the patient and provide anesthesia care.

Coverage of Monitored Anesthesia Care (MAC)

During monitored anesthesia care (MAC), close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the surgical procedure may become more extensive and/or result in unforeseen complications requires comprehensive monitoring and/or anesthetic intervention.

The following requirements for this type of anesthesia should be the same as for general anesthesia with regard to:

Ø  The performance of preanesthetic examination and evaluation.

Ø  The prescription of the anesthesia care required.

Ø  The completion of an anesthesia record.

Ø  The administration of necessary medications and the provision of indicated postoperative anesthesia care.

For procedures that do not usually require anesthesia services, MAC could be covered when the patient’s condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented in the patient’s medical record.

The presence of an underlying condition alone, as reported by an ICD-9-CM diagnosis code, may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact on the need to provide MAC such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily sufficient.

Therefore, in cases were the anesthesia is usually provided by the attending surgeon and are included in the global fee and are not separately billable, MAC provided by anesthesia personnel may be necessary due to active and serious accompanying situations or conditions to ensure smooth anesthesia (and surgery) by the prevention of adverse physiologic complications.

If this is your case, the use of anesthesia modifiers is required as follows:

ü  G8 anesthesia modifier – used to indicate certain deep, complex, complicated or markedly invasive surgical procedures. This modifier is to be applied to the following anesthesia codes only:  00100, 00300, 00400, 00160, 00532 and 00920.

ü  G9 anesthesia modifier – represents “a history of severe cardiopulmonary disease” and should be utilized whenever the proceduralist feels the need for MAC due to a history of advanced cardiopulmonary disease. The documentation of this clinical decision-making process and the need for additional monitoring must be clearly documented in the medical record.

Additionally, anesthesia physical status modifiers must be appended to indicate the clinical condition of the patient receiving MAC: 

P1 – healthy individual with minimal anesthesia risk, 

P2 – mild systemic disease, 

P3 – severe systemic disease with intermittent threat of morbidity or mortality, 

P4 – severe systemic illness with ongoing threat of morbidity or mortality, 

P5 – premorbid condition with high risk of demise unless procedural intervention is performed.

Special conditions and/or criteria must be supported by documentation in the medical record.

Reimbursement for MAC will be the same amount allowed for full general anesthesia services if all requirements listed under these indications are met. The provision of quality MAC is mandatory and requires the same expertise and the same effort (work) as required in the delivery of a general anesthetic.

Documentation requirements

Hospital, outpatient, ASC or office records should clearly document the reason for the MAC (e.g., the patient’s condition that requires the appropriate anesthesia; indications the procedure performed was deep, complex, complicated or markedly invasive).

The medical record should include a pre-anesthesia evaluation including a history and physical exam.

The medical record should include evidence of continuous monitoring of the patient’s oxygenation, ventilation, circulation and temperature.

The medical record should include a post-anesthesia evaluation of the patient including any unusual events or complications and the patient’s status on discharge.

Billing Tips

Anesthesia for Multiple Surgeries
Payment may be made for the anesthesia services provided during multiple or bilateral surgery procedures. When billing anesthesia services associated with multiple or bilateral surgeries, report only the anesthesia procedure with the highest base unit. Report the total time in minutes for all procedures on one detail line item.

Administration of Anesthesia by the Surgeon
Reimbursement for anesthesia performed by the operating surgeon is included in the allowance of the surgical procedure rendered during the same operative session. Separate payment is not allowed when surgeon performs the surgical procedure and performs local or surgical anesthesia.
No claim should be submitted for the anesthesia service.

Anesthesia Time

Anesthesia time begins when the anesthesiologist starts to prepare the patient for the procedure. Normally, this service takes place in the operating room, when monitoring start. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.

Anesthesia unit calculation

To calculate the amount of anesthesia units, divide the total anesthesia time in minutes by 15.

Time in Minutes	Anesthesia units
1-15	1
16-30	2
31-45	3
46-60	4

 

**Note: If the surgery is non-covered, the anesthesia is also non-covered**

 Source: Medicare Claims Processing Manual, Chapter 12, Section 50(e) and Medicare Local and National coverage determination.