Can You Pick The Right ICD-10 Family?

Remember those friends and family cell phone plans where you didn’t use minutes if you called people in your circle? You had to pick who you wanted in your group and they had to pick you. It was very confusing trying to figure out who was in the family and who wasn’t.

CMS created the same kind of confusion last week when it basically cut a deal with the American Medical Association (AMA). The AMA, you may recall, has been very vocally opposed to ICD-10 being implemented in any way, shape, or form.

To get AMA to cease and desist its defiance, CMS gave AMA something it wanted: no penalties for some coding errors and advanced payments if the technology goes kerflooey.

I can totally understand advancing payments if the system doesn’t work. That’s pretty straightforward. The physician gets paid on time and doesn’t have to worry about going under because of something he or she can’t control. The physicians will have to repay the advanced payment once the system is running smoothly, so they aren’t getting extra money. They just get a hedge against a Y2K meltdown.

The confusing part of the pact is the hold harmless for miscoding. AMA initially wanted physicians to get a pass on coding errors for two years. I’m pretty sure AMA knew that wasn’t going to fly, but when you negotiate, you always start high.

In the final deal, CMS stated auditors will not deny a claim “based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”

CMS does not, however, define a family of codes. Is it a category of codes, such as S00, superficial injury of head? That could be interesting. S00 has nine subcategories of codes, each with their own subcategories.

Or does CMS mean those subcategories, say S00.4, superficial injury of ear? Again, S00.4 includes eight subcategories with their own subcategories.

Maybe CMS considers a family to be the smallest group of subcategories. So under S00, we could go all the way down to S00.46-, insect bite (nonvenomous) of ear as a family. That would give us three codes in the family:

461, insect bite (nonvenomous) of right ear
462, insect bite (nonvenomous) of left ear
469, insect bite (nonvenomous) of unspecified ear

That seems reasonable. The only missing information is the laterality. Not a huge deal, but really the physician should be documenting it. Maybe the coder just couldn’t find it or was in a hurry and defaulted to unspecified.

Let’s consider open wounds of the eyelid and periocular area (S01.1). This is a subcategory under open wound of the head (S01). We’ve already narrowed it down to a specific area.

The question becomes, is everything under S01.1- a family? I hope not. Here’s why. The first subcategory under S01.1- is S01.10- (unspecified open wound of eyelid and periocular area). S01.10- further specifies laterality:

101-, unspecified open wound of right eyelid and periocular area
102-, unspecified open wound of left eyelid and periocular area
109-, unspecified open wound of unspecified eyelid and periocular area

That last one’s a killer because it tells you nothing. No wound type, no laterality.

Additional subcategories under S01.1- specify the type of wound:

Laceration with (S01.12-) and without foreign body (S01.111)
Puncture wound with (S01.14-) and without (S01.131) foreign body
Open bite (S01.15)

I can see not penalizing someone for failing to reporting the “without foreign body” code instead of requiring coders to query if the physician doesn’t document that no foreign body remained in the wound. The question of with or without foreign body becomes tricky when you start looking at subsequent encounters.

If S01.1- is a family, claims won’t be denied if you report S01.109- instead of S01.132- (puncture wound without foreign body of left eyelid and periocular area).

Fractures will be even more confusing, largely because ICD-10 includes so many variations of fracture codes.

What about specificity for diseases, such as diabetes? Where do you draw the family line? Is it the type of diabetes? So all codes under E11 (Type 2 diabetes mellitus) are one family?

Or do you go to the first subcategory and say all codes under E11.3- (Type 2 diabetes mellitus with ophthalmic complications) are the same family and therefore we won’t deny the claim if you have any E11.3- code.

Maybe CMS goes one step further and really narrows down the family to E11.31- (Type 2 diabetes mellitus with unspecified diabetic retinopathy), which includes two codes:

311, Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
319, Type 2 diabetes mellitus with unspecified diabetic retinopathy without macularedema

We don’t know. I’m not convinced CMS knows at this point.

Something else we don’t know—how does this deal with AMA affect hospitals? CMS and AMA both only reference Part B physician fee schedule claims. What about Part A claims? Is CMS going to extend the same breaks to hospitals? Again, we don’t know.

CMS may have finally gotten the AMA on board with ICD-10, but it sure created a lot of additional confusion along the way.
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Photo courtesy of: Medical Coding News

Originally published on: HC Pro