Health Information Management

Providers concerned about reporting unspecified ICD-10 codes and seventh characters

APCs Insider, October 2, 2015

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By Steven Andrews
ICD-10 is finally here. After several delays, both by CMS and Congress, and continued pressure by the AMA to scuttle the code set entirely, the transition has officially occurred.
Hopefully it’s going seamlessly at your facility, but coders will likely encounter scenarios and have questions about specific cases they didn’t come across while training. From coders I’ve talked to, and word from colleagues at this week’s AHIMA Convention, it seems two issues are cropping up the most.
The first is concern about unspecified codes and whether payers will reimburse claims that include them. Physicians have a bit more clarity due to the accord the AMA reached with CMS regarding families of codes, but that doesn’t extend to hospital reporting.
But that doesn’t mean hospitals aren’t allowed to report any unspecified codes. The ICD-10 guidelines cover this exact scenario:
While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter.
A lot of the fear generated by the AMA over unnecessary testing and documentation physicians would have to undertake in order to use ICD-10 was over a misunderstanding of the codes and guidelines. ICD-10 has plenty of cases where an unspecified code is justified.
Hospitals should check with payers regarding specific instructions. They may deny claims that don’t specify laterality, but providers should certainly be documenting that already.
Another concern for providers is choosing which seventh character to apply to codes that require them. The ICD-10 guidelines were updated to clarify language regarding seventh character reporting recently, so coders who trained years ago may have to take another look in order to apply them correctly.
Most codes that require a seventh character have three options:
  • A, initial encounter: Used while the patient is receiving active treatment for the condition. Some examples include surgical treatment, ED encounter, and evaluation and continuing treatment by the same or a different physician.
  • D, subsequent encounter: Used after the patient received active treatment for the condition and is receiving routine care during the healing or recovery phase. Examples of subsequent care include cast change or removal, an x-ray to check healing status of a fracture, removal of external or internal fixation device, medication adjustment, and other aftercare and follow-up visits following treatment of the injury or condition.
  • S, sequelae: Used for complications or conditions that arise as a direct result of a condition, such as a scar formation caused by a burn.
Categories for traumatic fractures have more available options for the seventh character. While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the seventh character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time, according to the Official Guidelines for Coding and Reporting.
Additionally, when deciding the seventh character for complication codes, the Official Guidelines for Coding and Reporting tell us that "active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem."
The example given to help us better understand this guideline involves code T84.50XA (infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter).
Coders would report T84.50XA when the physician is actively treating the infection, even though the condition relates to the prosthetic device, implant, or graft that was placed at a previous encounter.
Still have questions about ICD-10? See our archive of ICD-10 on-demand webcasts. Need more intensive training? Check out HCPro’s live and online Boot Camps.

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