We have been helping urology groups prepare for the Oct. 1, 2015 switch to ICD-10 for diagnosis coding. We have audited many charts, looked at EHR templates, taught webinars and seminars to many urologists, and have more seminars scheduled. Of course, Physician Reimbursement Services is not the only group sounding the alarm on ICD-10 codes. Two of the common themes we see in advertising for ICD-10 training courses are the increased number of codes in ICD-10 and the increase in specificity the codes allow.
We agree with these general statements, which apply to the entire system. However, the realities of the U.S. health care system should be used to encourage every health care provider to step away from the ledge, regroup, and take a more balanced approach to the transition. Are there going to be problems? Probably. But we would predict that the problems are going to initially be more about system glitches than inappropriate codes.
Comparing ICD-9 and ICD-10
Let’s look at one real example: coding for treatment of patients with cancer.
First, let’s take a look at current ICD-9 guidelines (first published in 2011) for diagnosis (Dx) coding as it relates to cancer. For the example, we will use bladder cancer, although many of these guidelines are general cancer guidelines and will apply to all cancer codes.
During ICD-9 or -10 training courses, you may have heard the directive to code what is known at the end of the encounter. In short, you are supposed to select the code for the symptom or diagnosis, which is documented in the record at the end of the service. Do not wait for the pathology report or other information to go back and report the diagnosis for an encounter or service provided.
ICD-10 carries more explicit instructions, but the instruction is clearly the same: “Each healthcare encounter should be coded to the level of certainty known for that encounter.”
Using our simplified bladder cancer example: A patient upon cystoscopy is noted to have one lesion 0.5 cm on the left lateral wall of the bladder; the lesion is biopsied and resected.
Dx known for the encounter:
- ICD-9: 239.4 Neoplasms of unspecified nature: Bladder
- ICD-10: D49.4 Neoplasm of unspecified behavior of bladder.
Typically, after the biopsy report is returned and the lesion is determined to be malignant, the patient is then scheduled for BCG treatment directed at the malignant neoplasm to ensure the cancer has been eradicated.
A typical note would read: Patient returns for BCG following resection of 0.5 cm malignant lesion of bladder wall. BCG instilled. Pt. tolerated the procedure well and return for repeat treatment in 3 months.
Dx known for the BCG encounter:
- ICD-9: 188.2 Malignant Neoplasm Of Bladder: Lateral Wall Of Urinary Bladder
- ICD-10: C67.2 Malignant neoplasm of lateral wall of bladder.
The Dx we actually see for many offices currently reporting this service with documentation such as this is:
- 188.9 Malignant Neoplasm Of Bladder: Bladder, Part Unspecified
In short, we already have specificity for many codes that we are not using to report the correct diagnosis. Most are paid using this diagnosis. As a further demonstration of the inaccuracy of this coding, here are the following instructions in both ICD-9 and ICD-10.
ICD-9/Chapter 2: Neoplasms (140-239)/General guidelines
a. Treatment directed at the malignancy
If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.
The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate V58.x code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.
ICD-10/Chapter 2: Neoplasms (C00-D49)/General guidelines
a. Treatment directed at the malignancy
If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.
The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate Z51.– code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.
Codes have changed, guidelines haven’t
Obviously, the codes themselves have changed, but the guidelines are identical. If all offices were to follow these guidelines and payers were restricting payment only to correctly diagnosed encounters, the following ICD-9 diagnoses would be reported (in appropriate order):
- V58.12 Encounter For Other And Unspecified Procedures And Aftercare: Encounter For Chemotherapy And Immunotherapy For Neoplastic Conditions: Encounter For Antineoplastic Immunotherapy
- 188.2 Malignant Neoplasm Of Bladder: Lateral Wall Of Urinary Bladder
For ICD-10 Dx coding for BCG in treatment phase:
- V58.12 Encounter For Antineoplastic Immunotherapy
- C67.2 Malignant neoplasm of lateral wall of bladder
Once the patient has completed BCG treatment or is deemed in the patient record to be free of cancer and is moved to surveillance cystoscopy to monitor for recurrence, ICD-9 and ICD-10 provide the following guidelines for coding.
ICD-9/Chapter 2: Neoplasms (140-239)/General guidelines
d. Primary malignancy previously excised
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code.
ICD-10/Chapter 2: Neoplasms (C00-D49)/General guidelines
d. Primary malignancy previously excised
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code.
Based on these guidelines, Dx coding for visits in which surveillance cystoscopy is performed and the results of the cystoscopy are negative or the bladder is noted to be clear should be as follows:
- ICD-9: V10.51 Personal History Of Malignant Neoplas: Urinary Organ: Bladder
- ICD-10: Z86.51 Personal history of malignant neoplasm of bladder.
If there is a recurrence of bladder cancer that is verified and documented, services during treatment of the next occurrence would be coded to the appropriate malignant neoplasm of the bladder code until once again eradicated.
While this example does not cover all the nuances of coding for cancer in all organs or types of cancer, the general rules apply to other organs treated. We did not cover metastatic disease due to space; these scenarios are also governed similarly in both ICD-9 and ICD-10.
Conclusions
Look at how you are coding in your own practice and whether you are being paid for the services you provide. Consider as well that although ICD-10 has been used by the rest of the world for over a decade, the rest of the world does not use CPT for payment and does not use ICD coding to restrict or verify payment validity. In short, the data systems that are being used today to determine payment with ICD-9 in the U.S. will be the same data sets that will be used to determine payment using ICD-10, with the obvious use of crosswalks to ICD-10 codes.
Some have asked about other diagnosis codes for underlying patient conditions, fearful that the new system will require five or more diagnoses in order to process the claim. Again, we point back to ICD-9 and the current rules, which are similar to those in ICD-10. Are you having to submit five or more codes to get paid? Are you required to list all the underlying diseases to get paid for the treatment of a urology-specific problem? In most cases, the answer is no.
Will payer systems eventually become more sophisticated and be implemented to further restrict payment? Probably.
There is another path and we are on it. With the Physician Quality Reimbursement System, meaningful use, value-based modifier, the merit-based incentive payment system (soon), and a market shift to value/quality-based payment, the payers—including Medicare—can afford to allow poor coding in the straight fee-for-service world to continue in the short term. As the system moves beyond the pure fee-for-service world, you will be compared to your colleagues for cost-efficient care. One easy place to start comparing quality is to look at those providers who can demonstrate results through Dx.
Following a Dx progression in which a patient is diagnosed with a lesion, cancer is identified and treated appropriately during the active treatment phase, followed actively in the aftercare phase and then declared as having a history of cancer is much more desirable to a patient who still has cancer.
We hope this article has provided at least a small amount of comfort in pointing out that the system change on Oct. 1, 2015 will not be the Armageddon that many have predicted.
However, you all know that PRS’s approach to coding is all about accuracy. Mistakes happen; correct them and move on. Ignorance, whether deliberate or not, will eventually catch up with you. We also look toward the future and see that accuracy in diagnosis coding must improve if you are going to survive in a reimbursement system based on quality.
We strongly recommend that you take the next few months to clean up your ICD-9 coding. We also recommend that you work toward making certain that you understand the rules you will be judged by under ICD-10. Learn the crosswalks and adjust them to accurately reflect what you do. You will also need to learn the new ICD-10 coding system. Update your templates and coding tools and make sure that your staff has access to knowledge, training, and tools that allow them to succeed in the tasks you have hired them to perform.
ICD-10 will be implemented. But do not panic. Take your time and learn the system correctly. Your future will depend on it.
