Medicare ICD-10 Coding
Flexibility – How It Works
By Seth Flam, DO
HealthFusion/MediTouch
Early in July, at the urging of
the AMA and other physician organizations, CMS agreed to offer flexibility with
regard to ICD-10 coding during the first year of implementation: October 1,
2015 – September 30, 2016. In our July 6 blog post (http://healthfusion.com/blog/2015/claims-clearinghouse/icd10/ama-12-month-icd-10-grace-period-accepted-cms/),
we outlined the new rule – and a key component of that rule centers on claim
denial “flexibility:”
Claim denials – For the first year ICD-10 is in place, Medicare claims will
not be denied solely based on the specificity of the diagnosis codes as long as
they are from the appropriate family of ICD-10 coding. This means that Medicare
will not deny payment for these unintentional errors as practices become
accustomed to ICD-10 coding. In addition, Medicare claims will not be audited
based on the specificity of the diagnosis codes as long as they are from the
appropriate family of codes.
Breaking down “specificity” and
what the “same family of codes” means
ICD-10-CM is composed of codes
with three, four, five, six or seven characters. Codes with three characters
are included in ICD-10-CM as the heading of a category of codes that may be
further subdivided by the use of fourth, fifth, sixth or seventh characters to
provide greater specificity. A three-character code is to be used only if it is
not further subdivided, most codes are more than three characters, but the
first three characters are key to understanding the “same family of codes”
flexibility rule.
Discover the anatomy of an
ankle sprain code, for example
Your patient presents for a
subsequent visit for a Right Ankle Sprain and you determine that the Right
Deltoid Ligament was recently sprained.
General Description: Sprain of the Deltoid Ligament of the Right Ankle –
Subsequent Visit:
S93.421.D (ICD-10 Code) – Sprain
of Deltoid Ligament of Right Ankle, Subsequent Encounter
Family or category:
XXX – S93 – Dislocation and
sprain of joints and ligaments at ankle, foot and toe level
Add More Specificity to
Identify the Ankle:
XXX.X – S93.4 – Sprain of ankle
is distinguished from other parts of the anatomy and other types of injury –
not foot or toe and from dislocation
Add More Specificity to
Identify Which Ankle Ligament:
XXX.XX – S93.42 – Sprain of
Deltoid Ligament of the Ankle
Add More Specificity to
Identify Which Side (lateralization):
XXX.XXX – S93.421 – Sprain of
Deltoid Ligament of the Right Ankle
Add More Specificity to
Identify Encounter Type:
XXX.XXX.X – S93.421.D – Sprain
of Deltoid Ligament of the Right Ankle – Subsequent Encounter
In the example captioned above,
the family or category of code is the first three places of the code. For this
code the user must code to the full seven digits including the encounter type,
which can be either:
1. Initial Encounter
2. Subsequent Encounter
3. Sequela
If the user had to manually build
the code from the three-digit family code to the final seven-digit code, it
would be almost impossible for anyone to succeed. In this case, because only a
seven-digit code is allowed, most advanced EHR products will never allow the
user to submit a code for an ankle sprain that is less than the required
seven-digit code.
The anatomy of an ICD-10 code
Now that we understand the anatomy
of an ICD-10 code, we can better understand the CMS flexibility rule.
Medicare claims will not be denied
solely based on the specificity of the diagnosis codes as long as they are from
the appropriate family of ICD-10 codes.
What other choices are
available for Ankle Sprain that are the in same family or category of codes?
Below, in Table 1, is a list of
Ankle Sprain codes that all are in the same family as defined by the first
three digits of the ICD-10 code. Per the CMS flexibility rule, a provider would
not be denied payment if one of those codes were used, even though the most
appropriate code was the one we worked with in our anatomy of a code example
above:
S93.421.D (ICD-10 Code) -
Sprain of Deltoid Ligament of Right Ankle, Subsequent Encounter
It is unlikely that a provider
will go through the trouble of coding to the specificity outlined above and
then purposely choose the incorrect ligament or ankle. If that’s the case then
how might the flexibility rule help a provider? The answer is in the unspecified
codes.
Many EHRs may match an ICD-9 code
with an ICD-10 code based on a file published on the CMS website called the
GEMS (General Equivalence Mappings) file. The data in that file attempts to try
to find an ICD-10 code that matches an ICD-9 code.
Example: IDC-9 to ICD-10 for
Ankle Sprain
If your patient’s current
diagnosis is Other Ankle Sprain with an ICD-9 Code of 845.09 then the GEMS file
may return an equally non-specific code such as:
S93499A: Sprain of other
Ligament of Unspecified Ankle, Initial Encounter.
You may choose this code even
though we know that the more appropriate code for our sample patient is:
S93.421.D: Sprain of Deltoid
Ligament of Right Ankle, Subsequent Encounter
If you choose S93499A: Sprain of other ligament of unspecified ankle, initial
encounter instead of the more specific code CMS will not be able to deny the
claim in the first year of ICD-10 even though there is a more specific code
that better describes the patient’s diagnosis. CMS won’t be able to deny the
code because the less specific code is from the same family as the more
appropriate and specific code. Because many EHR vendors will assist physicians
with mapping based on the GEMS file, the fact that physicians may use a less
specific GEMS file match may reduce denials.
For a list of FAQs regarding the
flexibility rule please read this CMS communication: (https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf).
Table of Ankle Sprain Codes
|
S93492S
Sprain Of Other Ligament Of Left Ankle, Sequela
|
S93492D
Sprain Of Other Ligament Of Left Ankle, Subsequent Encounter
|
S93492A
Sprain Of Other Ligament Of Left Ankle, Initial Encounter
|
|
S93491S
Sprain Of Other Ligament Of Right Ankle, Sequela
|
S93491A
Sprain Of Other Ligament Of Right Ankle, Initial Encounter
|
S93491D
Sprain Of Other Ligament Of Right Ankle, Subs Encntr
|
|
S93429D
Sprain Of Deltoid Ligament Of Unspecified Ankle, Subs Encntr
|
S93429A
Sprain Of Deltoid Ligament Of Unspecified Ankle, Init Encntr
|
S93429S
Sprain Of Deltoid Ligament Of Unspecified Ankle, Sequela
|
|
S93422S
Sprain Of Deltoid Ligament Of Left Ankle, Sequela
|
S93421S
Sprain Of Deltoid Ligament Of Right Ankle, Sequela
|
S93422A
Sprain Of Deltoid Ligament Of Left Ankle, Initial Encounter
|
|
S93422D
Sprain Of Deltoid Ligament Of Left Ankle, Subs Encntr
|
S93421A
Sprain Of Deltoid Ligament Of Right Ankle, Initial Encounter
|
S93421D
Sprain Of Deltoid Ligament Of Right Ankle, Subs Encntr
|
|
S93419A
Sprain Of Calcaneofibular Ligament Of Unsp Ankle, Init
|
S93419D
Sprain Of Calcaneofibular Ligament Of Unsp Ankle, Subs
|
S93419S
Sprain Of Calcaneofibular Ligament Of Unsp Ankle, Sequela
|
|
S93411S
Sprain Of Calcaneofibular Ligament Of Right Ankle, Sequela
|
S93412D
Sprain Of Calcaneofibular Ligament Of Left Ankle, Subs
|
S93412A
Sprain Of Calcaneofibular Ligament Of Left Ankle, Init
|
|
S93411D
Sprain Of Calcaneofibular Ligament Of Right Ankle, Subs
|
S93411A
Sprain Of Calcaneofibular Ligament Of Right Ankle, Init
|
S93412S
Sprain Of Calcaneofibular Ligament Of Left Ankle, Sequela
|
|
S93439A
Sprain Of Tibiofibular Ligament Of Unsp Ankle, Init Encntr
|
S93439D
Sprain Of Tibiofibular Ligament Of Unsp Ankle, Subs Encntr
|
S93439S
Sprain Of Tibiofibular Ligament Of Unsp Ankle, Sequela
|
|
S93432D
Sprain Of Tibiofibular Ligament Of Left Ankle, Subs Encntr
|
S93432A
Sprain Of Tibiofibular Ligament Of Left Ankle, Init Encntr
|
S93431S
Sprain Of Tibiofibular Ligament Of Right Ankle, Sequela
|
|
S93431D
Sprain Of Tibiofibular Ligament Of Right Ankle, Subs Encntr
|
S93431A
Sprain Of Tibiofibular Ligament Of Right Ankle, Init Encntr
|
S93432S
Sprain Of Tibiofibular Ligament Of Left Ankle, Sequela
|
|
S93499S
Sprain Of Other Ligament Of Unspecified Ankle, Sequela
|
S93499D
Sprain Of Other Ligament Of Unspecified Ankle, Subs Encntr
|
S93499A
Sprain Of Other Ligament Of Unspecified Ankle, Init Encntr
|
|
S93401D
Sprain Of Unspecified Ligament Of Right Ankle, Subs Encntr
|
S93401A
Sprain Of Unspecified Ligament Of Right Ankle, Init Encntr
|
S93402D
Sprain Of Unspecified Ligament Of Left Ankle, Subs Encntr
|
|
S93402A
Sprain Of Unspecified Ligament Of Left Ankle, Init Encntr
|
S93401S
Sprain Of Unspecified Ligament Of Right Ankle, Sequela
|
S93409S
Sprain Of Unspecified Ligament Of Unspecified Ankle, Sequela
|
|
S93409A
Sprain Of Unsp Ligament Of Unspecified Ankle, Init Encntr
|
S93409D
Sprain Of Unsp Ligament Of Unspecified Ankle, Subs Encntr
|
S93402S
Sprain Of Unspecified Ligament Of Left Ankle, Sequela
|
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About the author: Dr. Flam is one of the founders of HealthFusion and
serves as the company's CEO and President. He is board certified in Family
Practice and is one of the creative forces behind MediTouch EHR. More
information about Dr. Flam can be found at www.SethFlam.com
