August 30, 2016
By Melissa Pizor, COC, CPC, CPCO, CPMA, CPRC
The 2017 ICD-10-CM Official Guidelines for Coding and Reporting have been released on the Centers for Medicare & Medicaid Services (CMS) website. This latest version includes several notable changes to generalized guidelines. These changes become applicable as of October 1, 2016.
The beginning of the guidelines includes instructions to help identify the changes and revisions:
- Narrative changes appear in bold text
- Items underlined have been moved within the guidelines since the FY 2016 version
- Italics are used to indicate revisions to heading changes
One of the most significant generalized clarifications is an exception to the Excludes1 definition within Section I.A.12(a). CMS defines an Excludes1 note as an indication “that the code excluded should never be used at the same time as the code above the Excludes1 note.”
“An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.”
Several other generalized guideline changes to take note of are as follows:
Item No. 13 clarifies guidelines relating to laterality. Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left side, right side, or both (bilateral). If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.
When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second treatment encounter, after one side has been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition at the previously treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.
Item No. 16 clarifies guidelines relating to Documentation of Complications of Care: Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to remember that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification if the complication is not clearly documented.
It is also very important to note that the Medicare ICD-10 flexibilities agreement will end and will not be extended beyond October 1, 2016.
In 2015, both CMS and the American Medical Association (AMA) jointly announced guidance that would allow for “flexibility” in the claims auditing and quality reporting process for the first year of ICD-10 implementation. “ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud.” wrote CMS. This flexibility later became known as the “grace period.”
CMS also stated that beginning October 1, 2016, review contractors will be able to use “coding specificity as the reason for an audit for a denial of a reviewed claim to the same extent that they did prior to October 1, 2015.”
The bottom line is it will still be crucial to assign codes that are not only valid but also specific. The use of nonspecific codes may result in claim denials and loss of payment. Please review the new guidelines thoroughly in order to fully understand the impact to coding practices.