EDITOR’S NOTE: Dr. Wilbur Lo reports on coding ASD in ICD-10 as part of ICD10monitor’s coverage of the advantages of coding and documenting ASD in ICD-10.

According to the National Institute of Mental Health, Autism Spectrum Disorder (ASD) is characterized by a wide range of symptoms and levels of impairment or disability that are typically recognized during the first two years of life. ASD is a complex clinical diagnosis and includes deficits in social communication and social interaction, as well as restricted, repetitive patterns of behavior, interests, or activities. The symptoms will cause significant impairment in social, occupational or other important areas of functioning.

This article will focus on the importance of properly documenting ASD, with respect to the ICD-10 code set and to the Department of Health and Human Services’ Hierarchical Condition Categories (HHS-HCCs) under the Affordable Care Act (ACA).

According to the Centers for Disease Control and Prevention, there is an increased prevalence of ASD. In 2000, ASD affected one in 150 children, compared to affecting one in 68 children in 2010. The estimated costs are between $17,000 and $21,000 more each year to care for a child with ASD, compared to a child without ASD. In 2011, the estimated total societal costs were over $9 billion to care for children with ASD—if these costs are extrapolated to 2014 or 2015, they would be astronomical.  

Proper clinical documentation is a cornerstone and ensures complete, consistent, clear, precise, and timely information about the patient encounter, so that the patient receives proper treatment from the health care team within the continuum of care. If a physician treats an asthmatic child with ASD, but fails to document ASD in the medical record, what are the ramifications? First, without knowledge that the child has ASD, the other healthcare workers may not be able to provide proper treatment for the developmental, psychiatric, neurologic, chromosomal, and genetic disorders associated with ASD. 

Also, according to the Centers for Medicare and Medicaid Services (CMS), ASD is a complication and comorbidity (CC), which will result in increased utilization of resources and will increase the length of hospital stay by at least one day in 75 percent of the cases. By not capturing the diagnosis of ASD, the facility will receive inappropriate reimbursement for its services. The failure to document ASD will lead to lower severity of illness (SOI) and risk of mortality (ROM) scores and it will appear that the physician treated healthier patients, instead of sicker patients. This will affect the physician profiling and the negotiation of contracts with the insurance companies.

The ICD-10 code set is more specific and clinical than the ICD-9 code set. The ICD-10 code set contains approximately five times as many diagnoses codes and 19 times as many inpatient procedure codes as the ICD-9 code set. This explosion in codes may intimidate some physicians. However, there is a consensus that physicians appreciate the alignment of the ICD-10 code set with evidence-based clinical guidelines. 

With respect to ASD, the ICD-10-CM alphabetic index includes “atypical autism,” which appears as code F84.9 in the ICD-10-CM tabular list. Also, the “use additional code” guidelines under category F84 instruct the coder to “identify any associated medical condition and intellectual disabilities.” Associated medical conditions include tactile hypoesthesia and hyperesthesia, hyperacusis, insomnia, seizures, and Fragile X syndrome. It is essential for the clinician to document these findings because the proper assignment of codes—whether from the ICD-10 or ICD-9 code set—hinges on accurate and complete documentation practices.

In addition, proper clinical documentation impacts insurance plans via the HHS-HCC risk adjustment model under the ACA. The HHS-HCC risk adjustment model, which is based on the CMS-HCC risk adjustment model, predicts commercial insurance payments and reflects salient conditions and cost patterns for adult, child, and infant populations. Whereas, the CMS-HCC risk adjustment model predicts Medicare insurance payments for only the mature population (65 years or older) and the disabled population (younger than 65).

In the HHS-HCC model, demographics and diagnoses determine each individual’s risk score, which is an estimation of the individual’s anticipated healthcare costs. According to a 2014 study by CMS, autistic disorder is the fifth most prevalent HCC in children (behind asthma; major depressive and bipolar disorders; seizure disorders and convulsions; and diabetes without complication). Children with at least one HCC will require more visits to healthcare providers, more treatment and procedures, and increased healthcare costs. Although only 9 percent of children have one or more HCCs, this subpopulation of children will account for the majority of healthcare costs for the entire population of children.

HCCs are hierarchical because one HCC code is assigned for the most severe manifestation within each system. Assume that a child has personality disorder (HCC 090), autistic disorder (HCC 102), and asthma (HCC 161). Since the personality disorder and autistic disorder belong to the same system, the child will be assigned the HCC code for autistic disorder because the autistic disorder has a higher coefficient (weight). Because asthma is from a different system than autistic disorder, the child would be assigned a second HCC code for asthma. The sum of the coefficients of autistic disorder (HCC 102) and asthma (HCC 161), along with the child’s age, sex, and type of cost-sharing plan (Platinum, Gold, Silver, Bronze, and Catastrophic), will determine the child’s individual plan liability risk score. It is crucial for the physician to document all of the patient’s conditions, in order to capture all of the HCCs. 

Cumulatively, plans with lower individual risk scores will have lower average risk scores. Based on the Risk Transfer Formula, these plans will be required to make payments into a pool that will redistribute the payments to plans with higher average risk scores. As such, commercial insurance plans will receive incentives for value and, in turn, will expect the physicians to provide value in patient care and in the documentation of patient care.

About the Author

Wilbur Lo, MD, CDIP, CCA is a CDI consultant and a physician CDI advisor for ICDLogic.  Dr. Lo is passionate about advancing the medical and the health information management professions.

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