In less than six months, on Oct. 1, 2015, the health industry is changing from ICD-9-CM to ICD-10-CM for diagnosis coding. While most of the coding changes do not directly affect anesthesiology diagnosis practices (e.g., right vs. left breast or initial vs. subsequent encounter for fracture), it is not yet known how well payers will accept “unspecified” code options.

Anesthesiologists can start now to secure a smooth transition from ICD-9 to ICD-10 — and decrease the likelihood of denials — by ensuring they are receiving complete diagnosis information from referring physicians/surgeons on every case. The diagnosis should support the medical necessity for the care which may require both enhancement of your anesthesia record documentation protocols and education of referring physicians/staff to help ensure that the reason for the service is properly and thoroughly documented.  ICD-10 may have up to seven digits and specificity has been expanded to include laterality, episode of care and the trimester of pregnancy. There is also an expanded use of combination codes that require much more specific information, i.e. certain conditions and associated symptoms. Examples of when a 7th character would be used are Encounter: Initial, Subsequent or Sequela.

Below are the most common scenarios of insufficient diagnosis information for anesthesia cases, and tips on how to address these errors.

  1. Medical Necessity for Preventative services
    Some preventive services have payment rules related to whether the procedure is for screening vs. diagnostic, and limitations on qualifying (“payable”) medically necessary diagnoses. Review your documentation to help ensure that the surgeon’s reason for request for anesthesia services is clear.
  2. Uncertain Diagnosis
    Coders cannot assign diagnoses that are uncertain. Wording such as “suspected,” “suggestive of” or “rule out” does not constitute a definitive diagnosis. If the patient doesn’t yet have a confirmed diagnosis, the referring physician should provide the patient’s presenting signs or symptoms. Codes that describe symptoms and signs, as opposed to diagnosis, are acceptable for reporting purposes when a related definitive diagnosis has not been established(confirmed ) by the provider.1
  3. Incomplete, Vague or Irrelevant Clinical History Supplied
    While knowing the procedure that was performed is helpful, this is not sufficient detail from which a diagnosis code can be assigned. And remember, diagnosis codes are used by payers to support the medical necessity of the service being charged — diabetes may well be an accurate diagnosis, but it wouldn’t support the need for a thyroid charge.
  4. Inaccurate or Invalid ICD Codes Supplied
    Does your submitted documentation have ICD-9 codes on it, or a blank line for the providers? Does the documentation submitted already have an ICD-9 code? If you have actual ICD-9 codes, those codes will be obsolete after Sept. 30, 2015. So it’s not too early to start updating your documentation to include ICD-10 codes. ICD-9 or ICD-10 numbers can easily be transposed or digits can be missing.
  5. Increased Specificity Required
    Even in ICD-9, diagnosis code options are often more specific than the information supplied. For example, were the products of conception, delivery and placentas, the result of a missed abortion, legal abortion or was it a retained placenta post-delivery? For vaginal or C-section delivery, documentation of normal vs. complications that occurred during labor/delivery, is required. Pregnancy codes now are identified by the trimester by utilizing a 5th or 6th character in which the condition occurred.  Additionally, abortion vs. fetal death defined as 20 weeks vs. 22 weeks in ICD-9. The peripartum or postpartum period is defined as immediately after delivery and continues for six weeks following delivery. The peripartum is defined as the last month of pregnancy to five months postpartum.2

Fracture codes now are coded based on the following information:

  • Type – displaced, non-displaced, open or closed, transverse, oblique, spiral, comminuted, segmental, Monteggia’s etc.
  • Laterality (left or right)
  • Anatomic Site of Bone – proximal, shaft, distal
  • with routine or delayed healing
  • and for nonunion and malunion and the
  • Episode of Care - Initial encounter, Subsequent encounter, Sequela

Diabetes codes are now combination codes that include the type of diabetes, the body system affected and the complications affecting that body system.3

  • Diabetes mellitus has been expanded to 5 categories:
  • Diabetes mellitus due to an underlying condition
  • Drug or chemical induced diabetes mellitus
  • Type 1 diabetes mellitus
  • Type 2 diabetes mellitus
  • Other specified diabetes mellitus

Key Points:

  • Check all documentation for complete diagnosis information, and contact referring physicians/surgeons if sufficient information is not provided.
  • Monitor the cases your billing vendor returns to you for incomplete diagnosis information and identify common threads, such as repeat offending referring MDs, or CRNA’s.
  • Address the errors at the source, and track them to help ensure issues are being fixed. Focus on higher dollar and higher volume first.
Author - Female

About the author

Mary Jo Gross, CPC, CANPC of Compliance – Anesthesia and Pain Management, McKesson Business Performance Services