EDITOR’S NOTE: Rhonda Buckholtz is scheduled to participate in a stakeholders’ national conference call being conducted by the Centers for Medicare & Medicaid Services today on the topic, “The ICD-10 Code Set Increased –Why?” Excerpts are in the following article.

ICD-10 has achieved much recent notoriety for its external cause codes. It’s fun to talk about those crazy codes, but they too often make for a shock-and-awe story that will derail the conversation about actual potential uses and benefits of ICD-10. 

The bottom line is that most of us will never have to utilize those codes. And while I can make a case on how the use of ICD-10 could potentially save us tons of money in administrative costs and burdens for both the provider and the health plan (not to mention the patient, in cases of injury), there are other ways we can benefit as well. 

Our claim forms are our first line of defense in supporting medical necessity and justification for the services and procedures for which we bill. Often in ICD-9 we have to use unspecified codes, as there is often not a better, specific code available to us. When we have to use unspecified codes we open ourselves up not only to further scrutiny but also to the administrative burden of proving ourselves to each health plan.

New Codes, Old Issues

Providers can benefit from the new codes for patients with chronic and recurrent conditions as well as in the key area of laterality. Many times with ICD-9 codes it becomes difficult to meet criteria for services, procedures, medications, and other matters, making the process of obtaining authorization time-consuming (via multiple phone calls, submissions of records, etc.).

ICD-10 expands on many of these clinical conditions, however, allowing for the reporting of acute, recurrent, and chronic conditions. Use of these codes allows for the indication that a patient has met the clinical criteria for a specific condition. This should not only spell out more clearly what the patient’s clinical condition is, but also possibly alleviate some of the administrative burden of proof.

For example, let’s say a person with bilateral osteoarthritis of the knees has a right knee replacement. While in the global period, this patient is seen for increased pain due to overuse of the left knee. Under ICD-9-CM, this might be seen as falling under the global definition for right knee surgery, as the laterality cannot be shown.

Even with the proper modifiers appended to the visit and any services (injections, etc.) that may be performed, the diagnosis code still looks to be involved with the surgery. With ICD-10, the laterality can be shown to indicate that it is covering two separate areas.

Another example is the utilization of weeks in pregnancy and seventh-character extenders for the identification of the fetus affected. There are many complications of pregnancy that now can be identified through the use of these codes, allowing for more appropriate adjudication of claims.

While we still don’t know how the codes ultimately will be interpreted by the health plans, the potential remains positive for our providers regarding the ability to reduce administrative burdens.

About the Author

Rhonda Buckholtz is vice president of ICD-10 education and training at AAPC. She has more than 20 years experience in health care, working in the reimbursement, billing and coding sector, in addition to being an instructor. She is responsible for all ICD-10 training and curriculum. She has authored many articles for health care publications and has spoken at conferences across the country. She is a co-chair for the WEDI ICD-10 Clinical workgroup and has provided testimony ongoing for ICD-10 and standardization of data for NCVHS. 

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