American Academy of Family Physicians
Thursday May 16, 2013

Date of service decides whether you use ICD-9 or ICD-10

With the Oct. 1, 2014, deadline for implementing ICD-10 coding approaching, you may be wondering how you will treat a claim that you submit in October 2014 for a service that your practice provided in September 2014? Do you use ICD-10 because the claim is filed after the implementation deadline, or do you use ICD-9 because the service was provided before the deadline?

The short answer is that the date of service determines which code set you use. Thus, even if you submit your claim on or after the ICD-10 deadline, if the date of service was before Oct. 1, 2014, you will use ICD-9 to code the diagnosis. Conversely, for dates of service on or after Oct. 1, 2014, you will use ICD-10. That means you need to make sure that your systems, third-party vendors, billing services, and clearinghouses can handle both ICD-9 and ICD-10 codes for claims filed in the months following Oct. 1, 2014.

While some trading partners may allow that ICD-9 and ICD-10 codes be submitted on the same claim when dates of service span the compliance date, not all of them will. This may mean splitting services into two claims: one claim with ICD-9 diagnosis codes for services provided before Oct. 1, 2014, and another claim with ICD-10 diagnosis codes for services provided on or after Oct. 1, 2014. Check your trading partner agreements.

For additional help, visit the American Academy of Family Physicians website for tools and articles to assist your practice with the preparation and change to this new system. You can also find news and resources on the Centers for Medicare & Medicaid Services' (CMS) ICD-10 website, which also includes the ICD-10 continuing medical education modules developed by CMS in partnership with Medscape.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday Dec 20, 2012

Begin the Beguine, or loosening up for some ICD-10 dance steps

Is it necessary to love big band jazz in order to properly understand the new ICD-10 coding? No, but it would certainly help with the fancy footwork involved.

The "Getting Paid" blog will address in coming posts what major changes to look for in specific chapters of ICD-10. In the meantime, we'll look at the new coding system's Conventions and Guidelines. These are all available for download on the CDC website.

First off, ICD-10-CM has 21 chapters, up from 17 in ICD-9-CM as codes for certain conditions either break off to form their own sections or get roped in with others. The V and E codes, which detail supplemental factors influencing a patient's health and the external causes of injury, will be incorporated in the main classification under ICD-10-CM. Meanwhile, diseases and conditions of the eyes and ears will get their own chapter, separated from their current home in the nervous system section.

Injuries will now be classified by site, and then by type. Postoperative complications have been moved to procedure-specific body system chapters. Also, some codes have been combined. For example, coding for type 1 diabetes mellitus with diabetic neuropathy will no longer require two codes (one for the diabetes and one for the neurological manifestation) but a single code of E10.21.

In ICD-10-CM, as with ICD-9-CM, notes and parenthetical instructions are still present. The manual will still use "code first" and "use additional code," as well as "includes" and "excludes" notes. Also remaining are "not otherwise specified (NOS)" and "not elsewhere classified (NEC)." The term "and" is interpreted to mean "and/or" when it appears in a code title within the tabular list. The word "with" is interpreted to mean "associated with" or "due to" when appearing in a code title.

On the other hand, certain symbols, such as the lozenge, section mark, and braces are disappearing. Instead, ICD-10 will use dashes at the end of a code to signal that it requires additional characters. One example is M84.47-, which could represent any fracture to an ankle, foot, or toe (M84.472 is a fractured left ankle). ICD-10 does two types of "exclude" notes to modify some codes. "Excludes 1" lists condition codes that can't be used at the same time as the primary code. "Excludes 2" notes conditions that are not part of the primary code but that a patient could present at the the same time, meaning that both codes being used together are acceptable.

The alphabetic index of ICD-10 is divided into two parts – the index to diseases and injuries and the index to external causes – while the type and format layout uses the same mechanics as ICD-9.  Morphology codes are no longer listed in the alphabetic index, and they no longer have a separate appendix in ICD-10.

As I said earlier, the tabular list is divided into 21 chapters. Some of the reclassifications of diseases to different chapters were done for better alignment.  Each chapter is then divided into subchapters that contain three characters and are similar to the ICD-9 foundations.  Each chapter in ICD-10 begins with a summary of the blocks and an overview of the categories within the chapter. Some of the subchapters are divided into even more specific subchapters. 

The takeaway? With all of the changes ahead with ICD-10, getting up to speed will likely be less of a graceful waltz and more of a frantic jitterbug. But the AAFP is here to help you get through it.

–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians

Monday Aug 27, 2012

It's official: ICD-10 delayed to Oct. 1, 2014

Department of Health and Human Services (HHS) Secretary Kathleen Sebelius made official a one-year delay in the implementation deadline for the ICD-10 diagnosis code set when she announced last Friday a final rule that sets the new compliance date at Oct. 1, 2014.  The delay, which was the subject of a proposed rule last April, is part of a final rule that will establish a unique health plan identifier, which HHS promises will "help cut red tape in the health care system." More to come on the HPID, as it's referred to. In the meantime, check out FPM's ongoing series of articles on ICD-10

Monday Apr 23, 2012

ICD-10 delay proposed, but that's not all

By now you have likely heard the Office of the Secretary of the Department of Health and Human Services (HHS) has formally proposed delaying the transition date for ICD-10-CM to Oct. 1, 2014. Good news for the practices that have not started or do not know when they will start preparing for ICD-10 (76 percent, according to today's reading of FPM's Reader Poll; vote and view the latest results in the left column of FPM's home page). You have an added year to get your plans in order and get caught up in preparing for this transition.

But this is not the only portion of this proposed rule that affects your practice. This rule also adds the implementation date for national unique health plan identifiers (HPID). By Oct. 1, 2014, all large health plans (i.e., payers) must apply for an HPID, just as physicians have applied for their national provider identifier (NPI). In addition, claims administrators, clearinghouses, and other entities involved in the claims process wil have the opportunity to adopt a national Other Entity Identifier (OEID). While this is good news in that it should eliminate some of the issues that occur with claims transmissions not routing to the correct claims administrators or payers, it will come with some costs to your practice.

By Oct. 1, 2014, your billing system must be equipped to include these numbers on your claims. Small health plans have until Oct. 1, 2015, to comply, which complicates matters because you may need to send the HPID on most but not all claims. If your software vendor or clearinghouse didn't fare well in the transition to the HIPAA (Health Insurance Portability and Accountability Act) 5010 electronic transactions standards, now would be a good time to discuss with them when they will start planning and working to achieve compliance with the HPID. The timeline provided in the proposed rule indicates that your systems should be ready to send test transmissions of claims with the HPID by April 1, 2013.

If you have comments on any of these proposals, the rule includes a comment period of 30 days from the date of publication in the Federal Register. Comments should include file code CMS-0040-P and may be submitted electronically on or in writing to Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-0040-P, P.O. Box 8013, Baltimore, MD 21244-8013.

While you'll have an extra year to get ready for ICD-10, there is another sizable task on the to-do list – to prepare your claims systems to submit the HPIDs. I guess it is true that what one hand giveth, the other taketh away.


Friday Oct 08, 2010

Accountable care organizations and the future of physician payment

This week, the Federal Trade Commission (FTC), the Centers for Medicare and Medicaid Services, and the Office of the Inspector General in the U.S. Department of Health and Human Services (HHS) discussed legal issues related to accountable care organizations (ACOs) during a public workshop in Baltimore.

As promised in the meeting agenda, an FTC panel debated circumstances under which independent health care providers participating in an ACO could engage in price point negotiations with private payers without running afoul of federal antitrust laws that prohibit price-fixing. Also, panel participants explored different ways in which the HHS secretary could exercise waiver authority or create new exceptions and safe harbors related to the physician self-referral law, the federal anti-kickback statute, and the civil monetary penalty law, for the purpose of encouraging the creation and development of ACOs. The AAFP submitted comments that were included in the meeting record, and the Academy will continue to track the progress of the issues discussed.
As I listened to the workshop and as I have thought about it since, my thoughts had less to do with how ACOs might be facilitated and more to do with what they might mean for coding by and payment of family physicians.  Regarding coding, I am inclined to think that ACOs will de-emphasize the importance of procedure and service coding while heightening the importance of diagnosis coding. My reason for thinking so is that I expect ACOs will be paid on something other than a fee-for-service basis and, in turn, will pay physicians accordingly. When payment is made, for example, on an episode-treatment or global capitation basis, coding of each individual service becomes much less important than it is under fee-for-service. At the same time, appropriate risk adjustment of global capitation or delineation of episodes of care will depend, at least initially, on correct and complete coding of each patient's condition(s), which is all about diagnosis coding.
Regarding the payments themselves, I am optimistic that family physicians can do well in an ACO model of health care delivery. Family medicine has long touted its value, essentially arguing that nobody can do it better for less. ACOs, according to proponents, are all about cost-effectiveness, which suggests that they will depend on family physicians to succeed. That dependency should create leverage for family physicians to be paid at a level that is commensurate with the value that they bring to the ACO. Of course, this assumes family physicians exercise this leverage and choose to play a key role in the formation and ongoing governance of ACOs. 
Admittedly, this is all a bit of crystal ball gazing on my part, and as my 401(k) results will attest, crystal ball gazing is not my strong suit. As in most matters, only time will tell, but I'd like to hear your predictions. What do you think?

Friday Sep 24, 2010

Get them while they're hot! And then, enjoy the freeze.

With time to spare, the editors of FPM magazine have provided not only an article describing the ICD-9 code changes that take place on Oct. 1, 2010, but an updated array of ICD-9 tools to help you bill the correct diagnosis codes for dates of service through Oct. 1, 2011.

The September/October issue of FPM includes the article as well as the FPM short list of ICD-9 codes for family medicine. The short list and a long list can be downloaded in PDF or Excel format from the ICD-9 resources page in the FPM Toolbox. The FPM superbill and a searchable ICD-9 database for PDA users have also been updated and can be downloaded there as well. Be sure to share these valuable resources with your staff.

We also have good news about future code updates. The ICD-9-CM Coordination and Maintenance Committee will implement a partial freeze of the ICD-9 and ICD-10 codes prior to the implementation of ICD-10 on Oct. 1, 2013.

The partial freeze will be implemented as follows:

  • The last regular, annual updates to both ICD-9 and ICD-10 code sets will be made
    on Oct. 1, 2011.
  • On Oct. 1, 2012, there will be only limited code updates to both the ICD-9 and ICD-10 code sets to capture new technologies and diseases.
  • On Oct. 1, 2013, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses. There will be no updates to ICD-9, as it will no longer be used for reporting.
  • On Oct. 1, 2014, regular updates to ICD-10 will begin.

The partial freeze should allow you, your staff, software vendors and payers to focus on ICD-10 training and implementation of ICD-10 codes for the next three years without having to also keep up with significant changes to either the ICD-9 or ICD-10 code sets.

During this time, FPM and the AAFP will continue to offer information and resources to help you through the ICD-10 training and transition and keep you up-to-date on any code changes due to new diseases effected during the freeze.

Thursday Oct 22, 2009

You might be a coding and payment geek if . . .

The arrival of the new ICD-9 manual recently reminded me that there are certain things that distinguish coding and payment geeks from otherwise "normal" people.  So, for your consideration, I offer you the top 10 signs that you might be a coding and payment geek:

10.  The first thing you associate with December is the arrival of the new CPT book.

9.  You actually get excited when your new coding books arrive.

8.  You wonder why the toy doctors bag you bought your kid doesn't include a claim form.

7.  You worry your family physician is undercoding your visit.

6.  You consider the Federal Register light reading.

5.  You write to CMS more than to your own mom.

4.  You actually understand Medicare's Sustainable Growth Rate formula.

3.  You collect past issues of CPT Assistant on eBay.

2.  When your family physician tells you that you have conjunctivitis, you wonder what the ICD-9 code for that is.

 And the number one sign that you might be a coding and payment geek:

1.  You actually understood the humor in this blog post!

Friday Oct 02, 2009

Getting paid for H1N1-related services

Do you know where to obtain H1N1 vaccine for your patients and how to bill payers for its administration?

Free H1N1 vaccine kits are available through your state health agencies. The Centers for Disease Control has published a list of who to contact for information on obtaining the vaccine. If you do not wish to provide the vaccine in your practice, you can use this list to determine where to refer your patients.

Most privately insured patients will have benefits for the H1N1 vaccine administration even if their health plan does not typically cover preventive services; this is due to collaboration between the U.S. Department of Health and Human Services and payers. Medicare allows physicians to provide and bill for both H1N1 and seasonal influenza vaccines on the same date. Medicare created a new G code for administration of the H1N1 vaccine; submit code G9141 with diagnosis code V04.81. It is not necessary to report a separate code for the vaccine itself, but if you prefer to include it in your documentation, use code G9142. If billed, this code will be denied since the vaccine is provided at no cost. For the standard seasonal influenza vaccine and administration, use codes G0008 for the administration, V04.81 for diagnosis, and the appropriate CPT code for the vaccine itself (i.e., 90655, 90656, 90657, 90658 or 90660). Medicare will not pay for an office visit if the sole purpose of the visit is vaccine administration but will if a significant, separately identifiable E/M service is provided on the same date.

Your local private payers may still be deciding on the coverage and payment for the H1N1 vaccine, but most national payers have provided some guidance. The recent creation of CPT code 90470 for H1N1 vaccine administration may cause some plans to issue revised instructions. We have requested updated guidance from national health plans and will update the AAFP resources on H1N1 with this information as we receive it. As with all services, practices should check the individual patient’s benefits when scheduling the services.

Finally, it’s important to know how to code and bill for care provided to patients who are sick with the flu. New influenza diagnosis codes took effect Oct. 1, 2009. Code 488.1 is specific to influenza due to the H1N1 virus. Code 487.1 is still valid for patients with influenza not otherwise specified and other respiratory manifestations such as pharyngitis, laryngitis or URI. Code 487.0 for reporting influenza with pneumonia is also still valid. When providing in-office testing for influenza, code 87804QW represents CLIA-waived testing for influenza by immunoassay with direct optical observation. Most rapid tests do not differentiate between Influenza A and B. However, for those that do produce two separate results, payers may accept 87804QW on one claim line and 87804QW59 on a separate claim line. As always, you should check with your individual payers for specific coverage and billing guidelines.

Thursday May 28, 2009

Everything's up-to-date in Kansas City

Last week, I received a call from a doctor's office inquiring why her claim for a B-12 injection might have been denied by a particular payer.  She indicated that they used Current Procedural Terminology (CPT) code 90772 to report the service. 

A quick check of my 2009 CPT book identified the problem.  Code 90772 has been deleted for 2009; the correct new code is 96372. 

It never ceases to amaze and amuse me when a physician's practice is not using the current versions of a CPT, Healthcare Common Procedure Coding System (HCPCS), or International Classification of Diseases, 9th Revision - Clinical Modification (ICD-9-CM) manual.  It does not take too many claims denied because of out-of-date codes to equal or exceed what it would have cost the practice to buy current copies of the necessary coding manuals.  Indeed, the ICD-9-CM manual is available on CD-ROM from the U.S. Government Printing Office for only $19.00, and HCPCS can be accessed freely on the Centers for Medicare and Medicaid Services web site (although I still prefer to use the manual version). 

So, take a moment right now, while you're thinking about it, and pull your CPT, HCPCS, and ICD-9-CM books off the shelf.  If they are not the most current versions (i.e., 2009, as I write this), then it's time to order new ones.  This ounce of prevention for denied and returned claims should more than equal the pound of cure found in resubmitting or appealing such claims. 

Thursday Jan 29, 2009

ICD-10: Y2K all over again?

People often see things differently. Two neighbors may call their county government offices, one to ask that weeds be sprayed along the road and another asking for a no-spray ordinance. Health care is not immune to such conflicting priorities.

Some are anxiously counting the days until the Oct. 1, 2013, deadline for adoption of the ICD-10-CM codes and the "granularity" they promise. I doubt many practicing physicians are among that group. A letter to the Centers for Medicare & Medicaid Services from Jim King, MD, chairman of the AAFP Board of Directors, left no doubt the AAFP did not support this change. That said, I hope you are not losing sleep, hoarding canned goods or preparing to duck for cover. The transition from ICD-9 to ICD-10 will create some challenges but will not likely result in widespread calamity.

Don't get me wrong. This is not your average annual code update. As reported by the American Academy of Professional Coders, when the Blue Cross Blue Shield Association converted the 164 ICD-9 codes included in FPM's model superbill to ICD-10, the resulting mess was seven pages longer than the original list. (The FPM Superbill has been updated for 2009; you can download it from the FPM Toolbox.) Clearly the ICD-10 code set is cumbersome compared to ICD-9, but it's not as difficult as learning to diagnose and manage the 68,105 conditions that may be reported with ICD-10. You can handle this.

Here are some things to consider as the Oct. 1, 2013, implementation deadline approaches:

1. You will no doubt soon receive ads for ICD-10 products and educational resources. Please don't waste your money. Learning a complex coding system that you will not use for nearly five years isn't productive, and changes could be made to the code set before 2013. Keep reading FPM and plan to learn more when implementation is closer.

2. Don't let ICD-10 overshadow another change with the potential for significant financial impact, especially for solo and small practices -- the conversion to the HIPAA 5010 electronic transaction standards, which must be completed by Jan. 1, 2012. Version 5010 is an extensive revision and paves the way for submission of ICD-10-CM codes. If your software vendor charges for upgrades or floundered during prior changes, now is the time to start asking questions about implementation plans and considering your options (e.g., upgrade or change vendors).

3. If you think you might need to change your software, consider a combined EHR/practice management system. A combined system may relieve some of the ongoing burdens and costs of transitioning to ICD-10. Imagine having an ICD-10 look-up tool similar to the FPM ICD-9 Look-Up Tool built into your EHR and integrated with your billing system, or a system that automatically converts standardized nomenclature to codes.

Most of you have endured the Medicare enrollment process, so you are combat-tested. And you are not alone. The AAFP and FPM will continue to provide you with the best resources that we can find or create to help you make the transition to ICD-10.

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