Coding

ICD-10 is here

The new coverage guidelines could present problems

BY PAUL M. LARSON, MBA, MMSC, COMT, COE, CPC, CPMA

After a few years’ delay, ICD-10 arrived on Oct. 1. You finally have to (get to?) use the new diagnosis coding system (but remember that CPT and all the associated location [RT, LT, E1-E4] and payment [25, 58, 79, etc.] modifiers do not change). You can’t avoid ICD-10 now, except with the very few payers such as workers’ compensation, homeowners, or automobile insurers who were never subject to the ICD-10 conversion mandate (although a change at a future date might be considered).

Here are problems that could potentially arise from newly instituted ICD-10 coverage guidelines, and what to do if you encounter them.

Edema code changes

Suppose you have an “old” ICD-9 policy that pays for OCT with a diagnosis of retinal or macular edema of various types. In ICD-9 this was done via one of three codes: 362.53 (cystoid macular edema), 362.83 (retinal edema), or 362.07 (diabetic macular edema [DME]).

The first of these, 362.53, converts to eight ICD-10 codes (laterality is a new concept in ICD-10 and is present with the two coding options):

The second of the three, 362.83, becomes a single ICD-10 code: H35.81; there is no laterality.

Lastly, ICD-10 coding for DME is incorporated into the “combination codes” that involve the type of diabetes mellitus (DM, type I or type II), retinopathy, and finally include the presence of DME. There is no laterality. For diabetics with macular edema, the eight most commonly encountered codes that contain DME are as follows:

Appealing denied claims

In looking at the 17 macular edema codes that “should be” listed in the new ICD-10 polices, check to be sure that each one is listed. What approach should you take if one or more of the above are not listed?

First, check to be sure that particular payer policy contains the above ICD-9 codes in the old policy and, if so, that it was “mapped” or converted properly into the current ICD-10 policy. If not, that alone is a basis for having the policy modified. Write a letter to the appropriate person at the payer — point out the old policy’s coding coverage, and specifically note the absence in the current policy coverage. For most payers, a formal policy change mechanism should be followed.

If you only look at the covered diagnoses after claims are denied and notice a significant coding absence, you need to appeal the claims denial and write to the payer for policy changes (as noted above). Appealing these denied claims should reference the coverage with the old policy and the missing codes that should be in the new policy. Use the usual payer mechanism for claims appeal. Don’t give up; seriously consider getting your city, county, regional, state, or national eye organizations involved. Your office will not be the only one affected — these changes can benefit patients, too.

Conclusion

Carefully go over the new payer guidelines (Medicare and private payer), and look for the codes you are most likely to use in your practice. If you don’t see something, notify the payer and consider appealing (both the claim itself and the policy).

As always, “Good Coding” to you! OP

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.