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Prepare for ICD-10 Documentation Changes

Jun 25, 2015

Physicians need to understand the increased documentation requirements of ICD-10 prior to the October 2015 implementation date. Preparing now allows practitioners time to adjust to the increased specificity requirements. If providers’ documentation does not support the detail of the ICD-10 codes billed, they are at high risk of not being reimbursed and being penalized in the event of an audit. Future audits will likely focus on documentation support of the more detailed code set.

One new concept is laterality. This refers to the left or right side of the body and related organ structures. Currently, there is no such concept in ICD-9. In ICD-10, the following rules generally apply:

  • For bilateral sites, the final character of the codes in the ICD-10-CM indicates laterality.
  • The right side is usually character 1.
  • The left side is usually character 2.
  • If a bilateral code exists, the bilateral character is usually 3.
  • The unspecified side is either a character 0 or 9.

An example is the diagnosis of “shoulder pain.”  In ICD-9, there is only one applicable code, 719.41, Pain in joint, shoulder region. In ICD-10, there are 3 possible choices:

  • Pain in right shoulder, M25.511
  • Pain in left shoulder, M25.512
  • Pain in unspecified shoulder, M25.519

A significant concern arises when utilizing billing software conversion tools. In most software, the conversion of the ICD-9 code for Pain in joint, shoulder region will yield an ICD-10 code of Pain in unspecified shoulder. The physician may well know which shoulder is bothering the patient; however, if the doctor is not aware of this new concept in ICD-10 and relies on software conversion, the billing diagnosis may appear as though the practitioner is unaware of which shoulder he is treating. When insurance companies review claims, medical necessity for the procedure is one of the criteria for payment. It is unlikely that an insurance company will reimburse a claim for treatment of shoulder pain if the physician does not indicate which shoulder is being treated.

Prepare now to incorporate these new concepts into documentation. Failure to do so may result in denied claims or adverse audits in the future.

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