February 01, 2011
In looking at the new ICD-9-CM coding changes that go in effect October 1, 2010, you may be wondering if we are moving forward in the data collection in preparation for ICD-10 or if we are losing ground. There are some very exciting changes that help with specificity, which is a great indicator that the changes are helping us prepare for ICD-10. Yet other changes impact the MS-DRG system, especially in regards to CCs and MCCs-identifying that we are moving forward with severity of illness which impacts reimbursement-some changes are indicators as to hospital-acquired conditions and present on admission (POA) impacting reimbursement.
In anticipation of ICD-10, specificity seems to be the key to many of the changes made for FY 2011. For example, a fifth digit is now required for category code 275, disorders of iron metabolism. Fifth digits now identify whether the condition is hereditary (275.01), due to repeated red blood cell transfusions (275.02), other hemochromatosis (275.03), or other disorders of iron metabolism (275.09). Fluid overload, category code 276.6, is another area where fifth digits are now required for specificity identifying transfusion associated circulatory overload (276.61) or other fluid overload (276.09).
In the congenital anomalies chapter, anomalies of the uterus category code 752.3 now require a fifth digit to identify anomaly as agenesis (752.31), hypoplasia of uterus (752.32), unicornuate uterus (752.33), bicornuate uterus (752.34), septate uterus (752.35), arcuate uterus (752.36), and other anomalies of uterus (752.39). Anomalies of the cervix, vagina, and external female genitalia, category code 752.4 added additional fifth digit options to identify cervical agenesis (752.43), cervical duplication (752.44), vaginal agenesis (752.45), transverse vaginal septum (752.46), and longitudinal vaginal septum (752.47).
MS-DRGs Some of the new codes that have affected MS-DRGs and the complications/co-morbidities (CC) and major complications/co-morbidities (MCC) lists also address specificity issues. Examples include the Avian and H1N1 influenza codes, which now identify their manifestations with a fifth digit: 1- pneumonia, 2-other respiratory manifestations, or 9-other manifestations. If the fifth digit is a 1 then it can be an MCC; if the fifth digit is a 2 then it can be a CC, therefore potentially affecting reimbursement. Body mass index, V85.4 went through changes as well and now identifies BMIs all the way up to 70 and over in an adult. This still can be a CC when the BMI is 40 and over.
Some of the changes indicate a different impact on reimbursement for hospital-acquired conditions and POA (present on admission) reporting. Remember, for a condition to be identified as hospital-acquired it has to have a specific code. Some conditions that currently are identified with an ICD-9 code can be a hospital-acquired condition and impact payment when they are identified as not being present on admission. Some of these conditions are identified as "Never events" meaning they should never happen in a hospital. Therefore, if they would result in higher payment and were not present on admission then reimbursement is made on the MS-DRG without CC/MCC (as long as there are no other MCCs or CCs documented and coded). Since these conditions can affect reimbursement it is important that they be specific. For example, blood incompatibility codes category code 999 complications of Medicare care, not elsewhere classified went through some changes and now require a fifth digit. Category codes 999.6 ABO incompatibility, 999.7 Rh incompatibility, and 999.8 transfusion reaction all add specificity to identify whether the reaction was acute, delayed, or unspecified.
The good : Some of the good news for FY 2011 is the change to allow more diagnoses on the claim forms. Currently the UB-04 claim form allows for 17 secondary diagnoses codes and the fiscal intermediary (FI) is only required to look at the first eight. Starting in January 2011 the claim form will now allow for up to 24 diagnoses and 24 procedures, showing a move towards the severity of illness as the driving factor for reimbursement.
The bad: Some of the bad news is that 584.9 moved from the MCC list to the CC list. The trend seems to occur when a code is over-utilized then it is removed from the list or down-graded from an MCC to a CC. Just think back to 428.0, congestive heart failure, which no longer counts as a CC. Now more than ever, specificity is key.
The ugly: The ugly represents the changes in reimbursement which seems to be a result of the fact that we figured out the DRG and reimbursement system; but did we really? Claims submitted with CCs and MCCs seemed to be a focus since they result in higher reimbursement. The question being raised is whether these patients actually fall in the appropriate DRG based on the documentation of severity of their illnesses or if we seemed to be using criteria and definitions that many physicians cannot agree on in determining how sick the patient is and then requesting documentation of those diagnoses for coding and reimbursement. For example, sepsis seems to be a very subjective and debatable condition when it comes to coding and documentation of the condition. Coders are not to question the physician's clinical judgment based on coding guidelines; however, insurance companies seemed to be doing this on a regular basis when it comes to sepsis. If the definition of sepsis/SIRS and criteria is met in the medical record, how can an insurance company come back and say the patient doesn't have sepsis? Many physician and experts on the subject agree that something needs to be done about the definitions. Until this happens it appears the debate on whether it is sepsis/SIRS will continue.
Specificity is the focus of many of the new ICD-9 codes and documentation of the severity of illness is becoming more important than ever. Changes to the MCC and CC list identify the importance of documentation of specificity. As a coder it is becoming more important for us to educate ourselves on pathophysiology and continue to grow in our clinical knowledge in order to ensure the accuracy and appropriateness of our coding.
Jennifer Avery, CCS, CPC, CPC-I, CPC-H, is an instructor for HCPro's Revenue Cycle Institute where she utilizes her vast experience in both inpatient and outpatient coding by training and custom education porgrams. Avery serves as an instructor for the Certified Coder Boot Camp® both live and online, as well as the Certified Coder Boot Camp®-Inpatient Version. Prior to HCPro, she worked as a coding consultant and as a lead coder at a practice management company.