The diagnosis coding methodology used in ICD-9 means that many common medical conditions and situations are assigned vague codes out of necessity. Current medical practice and standards have not kept pace with a coding system that was devised over three decades ago. This ambiguity is the reason that ICD-10 is being adopted by the healthcare industry. When ICD-10-CM becomes the outpatient billing standard in 2014, physicians will need to rethink how to document patient encounters and how their documentation will affect their coding. Clean claims using ICD-10-CM billing practices will require expert knowledge.
Professional billing agencies, like M-Scribe, are already prepared to submit clean claims under the new coding system. The software has been programmed to accept ICD-10-CM codes, this was part of the recent 5010 conversion. Software is only part of the solution, however. No computer program will ever replace the professional skills and judgement of a human being. A HCFA-1500 is only as good as the person who enters the claim information. The coding will only be as good as the contents of the medical record.
Factors Influencing Health Status and Contact with Health Services
Both coding systems are designed to accurately describe congenital or pathological abnormalities in a patient’s health status. There are times, however, when a patient presents for a physician encounter that does not quality as a medical diagnosis.
Under ICD-9, these conditions are coded in the chapter entitled, “Supplementary Classification of Factors Influencing Health Status And Contact With Health Services, V01-V91.” These have always been troublesome when submitting healthcare claims since many of these cannot be considered a primary diagnosis. Some of these codes, such as those for counseling, can be primary diagnoses, such as V26.41, “Procreative counseling and advice using natural family planning.” There are very few codes in ICD-9-CM that indicate counseling is the primary reason for a patient’s visit to his or her physician.
ICD-10-CM on the other hand, utilizes the codes Z00-Z99 to discuss “Factors Influencing Health Status and Contact with Health Services.” As with many conditions that a physician encounters, there is no direct crosswalk between ICD-9 diagnosis coding concepts and those utilized in ICD-10-CM. ICD-10-CM represents a paradigm shift that provides for more granularity of data in the patient encounter reporting process. Consider this scenario in the primary care setting:
A patient reports for a routine three-month follow-up appointment hypertension and hypercholesterolemia. During the review of the patient’s history, the patient confides in his or her physician regarding a private matter, requesting medical advice. The appointment takes longer than 45 minutes, more than half of which is devoted to counseling about this specific issue. CPT allows for billing 99215 for this outpatient service, but the diagnosis needs to justify the high level E/M code. Neither high blood pressure nor high cholesterol can be used to justify the higher charge.
Using ICD-9-CM, only a non-specified code can be used to describe the issue that the physician spent extensive practice resources addressing. In all likelihood, this will be denied by the payer with a request for supporting documentation to audit the claim and determine the level of reimbursement. With ICD-10, the reason will be obvious the first time the claim is submitted.
In ICD-10-CM, Z70 refers to “Counseling related to sexual attitude behavior and orientation.” Unlike ICD-9-CM, ICD-10-CM specifies the exact nature of the counseling. With the required inclusion of additional characters, little is left to an auditor’s imagination. There is no need to review documentation because the diagnosis code tells the whole story. Z70 is broken down into four additional specific codes, one code to catch other specified issues, and one unspecified code:
Z70.0 Counseling related to sexual attitude
Z70.1 Counseling related to patient’s sexual behavior and orientation
Z70.2 Counseling related to patient’s sexual behavior and orientation of third party
Z70.3 Counseling related to combined concerns regarding sexual attitude, behavior and orientation
Z70.8 Other sexual counseling
Z70.9 Sex counseling, unspecified.
Diagnosis codes Z00-Z99 to discuss “Factors Influencing Health Status and Contact with Health Services" are one of the many benefits ICD-10-CM has over ICD-9.