Dermatology billing is always determined by the documentation contained in the medical record. Without thorough documentation, codes cannot be assigned accurately for clean claims. With the conversion to ICD-10-CM, dermatology billing is going to be even cleaner, provided the documentation is there to support it.
The amount charged by an outpatient dermatology practice is determined by the procedures performed in the office. Charges are linked to specific procedure codes. The more complex the procedure, the higher the reimbursement. This is based on practice and professional resources expended to provide the service. Under the current reimbursement system, ICD-9-CM codes are matched to procedure codes to justify medical necessity.
It has been recognized for years that ICD-9-CM does not contain the level of specificity required to accurately report medical necessity for many of the procedures performed in the field. Physicians read the code from the alphabetical index of ICD-9-CM Volume 2, and they assign a code without consulting the tabular list in Volume 1. More often than not, the result will be an unspecified code, and, more often than not, the claim will be paid without question. Payment is not proof that a clean claim has been submitted.
When a certified medical coder or biller reviews the medical record, he or she can usually find a more applicable code to describe the patient’s condition. Diagnostic coding does not usually effect procedural coding. This isn’t always the case in dermatology billing, as every dermatologist who excises neoplasms knows, but it is true more often than not. An inappropriate diagnosis code only affects reimbursement when the diagnosis is medically unbelievable, like a skin biopsy for hypertension.
Under ICD-9, because the system only contains only about 13,000 codes, many medical conditions that are documented in the medical record can only be assigned codes that are vague, unspecified, or that describe a wide range of similar, but distinct, pathologies.
ICD-10 contains approximately 68,000 codes. The new system is designed to better describe specific medical conditions, packing as much information as possible into a series of characters up to seven in length. The new diagnostic coding system will allow payers to set up more detailed edits to determine if medical necessity requirements are met.
ICD-10 is not being adopted to provide a means of rejecting more outpatient dermatology claims. On the contrary, it is being implemented on an industry-wide basis to more accurately report the services performed and why they were performed. It is expected that the new system will root out cases of fraud and abuse, but thorough documentation and accurate coding should result in faster claim turnaround, fewer appeals, and more accurate reimbursement.
The documentation contained in the patient’s medical record should already contain sufficient information to assign accurate ICD-10 diagnosis codes. That said, the information needed to assign correct ICD-10-CM codes is somewhat different from that needed to assign ICD-9-CM codes.
Consider the common dermatological condition of urticaria. Under ICD-9 methodology, urticaria falls in the 708 code set, requiring one additional digit. Under ICD-9, if the medical record states, “urticaria,” the code 708.9 is assigned, Urticaria, unspecified. If the medical record states, “allergic urticaria,” the code 708.0 is assigned, Allergic urticaria. In ICD-9-CM, there are eight codes used to describe urticaria.
Using ICD-10-CM, there are a number of separate codes used to describe urticaria. L50.0 describes a reaction due to drugs, food, and inhalants. If the patient presents with solar urticaria, a different code is used. L56.2 will be used on a healthcare claim for a patient with solar urticaria. Under ICD-9-CM this diagnosis is usually assigned 708.0 or, rarely, 708.8, Other specified urticaria. ICD-10-CM will eliminate the confusion behind assigning the codes by providing a specific code dedicated to solar urticaria.
This information should already be apparent in the medical record, but it will take a professional medical biller or coder to navigate ICD-10 to find the precise code definition that matches the documented diagnosis. When the right codes are used to bill, maximum, efficient reimbursement will follow.