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CMS Posts ICD-10 Guides Tailored for Six Specialties

September 16, 2015:

Physicians in six specialties now have online access to official “clinical concepts guides” outlining common ICD-10-CM codes used in each specialty, as well as clinical documentation tips and clinical scenarios. In August, the Centers for Medicare and Medicaid Services (CMS) posted the guides on its website as part of its “Road to 10” initiative to prepare physicians for ICD-10 implementation.

The guides compile in a PDF format key information from the online tools on the Road to 10 website for internal medicine, family practice, pediatrics, obstetrics/gynecology, orthopaedics, and cardiology.

The clinical documentation tips highlight important differences between the old coding system and ICD-10 by pointing out changes to definitions and terminology, as well as instances requiring greater specificity in documentation. Below is a sampling of what the guides discuss.

Definition changes:

  • Hypertension is no longer described as benign or malignant but as essential (primary) or secondary.
  • A myocardial infarction is now considered “acute” for four weeks from the time of the incident.
  • The timeframes for “missed abortion” and for differentiating early and late vomiting in pregnancy are now 20 instead of 22 weeks.
  • “Elective termination of pregnancy” is used instead of “elective abortion.”

Terminology changes:

  • “Underdosing,” a new term in ICD-10, describes a patient’s taking less of a medication than is prescribed.
  • “Pregnancy,” “childbirth,” and “puerperium” are concepts that are distinct from “trimester.”
  • Asthma terminology now reflects current descriptions. Documentation must note the cause, severity, and temporal factors, such as whether it is acute or chronic, or intermittent or persistent.

Increased specificity:

  • Fracture documentation must note up to nine key elements: type, pattern, etiology, encounter of care, healing status, localization, displacement, classification, and complications.
  • Documentation of diabetes must detail type, complications, and treatment.
  • When documenting otitis media, providers must describe the type (serous, sanguinous, etc.), infectious agent, temporal factors (acute, subacute, chronic, recurrent), side affected, presence of a tempanic membrane rupture, and secondary causes (such as tobacco smoke).

The clinical scenarios included in the guides present sample documentation, followed by a comparison of how the cases would have been coded under ICD-9-CM and how they are coded in ICD-10-CM. They then explain particular effects of ICD-10-CM on documentation and coding.

For example, the scenario for an annual physical exam for a 73-year-old man includes a note that documenting the reason for the encounter is important. For example, although the patient was recently hospitalized for hypertension, the exam is purely for screening purposes with no complaint mentioned at the outset. In this case, it is also important for the coder to reflect the new concept of “underdosing” since the patient reports stopping prescribed medication after experiencing headaches. The documentation must note any medical conditions linked to the underdosing that are relevant to the exam.

For this case, the guide notes that ICD-9-CM codes V70.0 (Routine medical exam), 401.9 (Unspecified essential hypertenstion), and 339.3 (Drug-induced headache, not elsewhere classified) would have described this encounter. There would have been no way to codify the patient’s suspension of medication or the reason behind it.

In contrast, the correct ICD-10-CM codes for this case are Z00.01 (Encounter for general adult medical examination with abnormal findings), I10 (Essential [primary] hypertension, G44.40 (Drug-induced headache, not elsewhere classified, not intractable), T46.5X6Z (Underdosing of other antihypertensive drugs, initial encounter), and Z91.128 (Patient’s intentional underdosing of medication regimen for other reason). This example makes clear how much more detailed ICD-10-CM is than ICD-9-CM.

The guide goes on to prompt coders to consider whether the new patient-centric preventative health incentives for annual exams apply to their practices. It also mentions that the impacts of hierarchical condition categories (HCC) used in Medicare Advantage Risk Adjustment plans are often overlooked when converting from ICD-9-CM to ICD-10-CM. Physicians should be documenting the status of all chronic and acute conditions at each annual exam, the guide explains, as HCC codes are payment multipliers. Not adequately reflecting a patient’s severity of illness, risk, and resource use can have a sizable impact on payment.


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