Medicare ICD-10 Coding Flexibility – How It Works

Medicare ICD-10 Coding Flexibility – How It Works

By Seth Flam, DO

HealthFusion/MediTouch

http://healthfusion.com/

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