How CMS Diagnosis Codes Can Improve Your Documentation and Revenue

Understanding ICD-10-CM Is Critical for Strengthening Your Bottom Line

Ambrose Bierce satirically defined “diagnosis” as “a physician’s forecast of the disease by the patient’s pulse and purse.”

It’s easy to joke about doctor’s earnings . . . unless you’re a doctor! You’re not in medicine just for the money. (It’s no fast track to riches anyway). But you do have to make sure you’re being paid what your hard work warrants.

That’s why CMS diagnosis codes matter.

Getting CMS and other payers to reimburse you fully isn’t only a matter of submitting the optimal CPT® code for patient visits (something the MDCodePro app helps you do with maximum accuracy and efficiency). Beyond identifying what procedures you perform, you need to choose the right diagnostic codes to establish why.

With CMS’ list of medical diagnosis codes running into the tens of thousands, that choice can seem overwhelming. But understanding how and why these codes developed can make them less intimidating and more useful to your patients, your profession, and your bottom line.


From 16 “Notorious Diseases” to 69K+ Diagnostic Codes

London haberdasher John Graunt published his statistical study of causes of death, Observations Made Upon the Bills of Mortality, in 1662. It included a “Table of Notorious Diseases” specifying 16 maladies, including “falling sickness,” “head-ach [sic]” and “lunatique.”  

Graunt’s Observations marked “a new approach to health issues,” states The BMJ: “reliance on evidence versus belief.” The book inaugurated modern demography. It also helped lay the foundation for what became today’s International Classification of Diseases (ICD), the system of codes used to report symptoms and diagnoses (as well as U.S. hospital inpatient procedures) in medical records and billing claims.

If Graunt could see how much disease classification has grown, he might feel as bewildered as many modern practitioners do. ICD-10-CM (the code sets’ tenth edition since adoption in 1893; “CM” stands for Clinical Modification) contains 69,823 diagnosis codes CMS and other payers recognize. That’s almost 400% more than the 14,025 codes in ICD-9.


How ICD-10 Diagnosis Codes Help Healthcare

CMS-Diagnosis-Codes By the time the U.S. adopted ICD-10 in 2015, ICD-9 had grown inadequate. It was placing a bigger documentation burden on providers because it lacked specificity; it was running out of space and numbers for new codes; and it was failing to usefully measure resources used, costs, or patient outcomes, as Anita Hazelwood wrote for AHIMA.

But utility and flexibility are hard-coded into ICD-10. Its codes can extend up to seven characters, as opposed to only three to five, allowing them to “represent more specific anatomic sites, etiologies, comorbidities, and complications, and . . . demonstrate severity of illness,” AHIMA trainer Donna Cartwright wrote. ICD-10 can easily accommodate new codes by means of an “x” placeholder. And it captures better data, yielding a better measurement of healthcare quality and effectiveness.

As you likely remember, the switch to ICD-10 caused a lot of consternation before it happened. But by and large, the changeover has gone smoothly. AHIMA deems logistical impacts largely negligible, limited in scope, and quickly resolved. That means the healthcare industry can now start taking advantage of ICD-10’s benefits.

More specific information in diagnostic coding means, as AHIMA’s Sue Bowman points out:

  • Cleaner data for researchers to help them make advances in disease management
  • More effective, customized treatment for patients, leading to more positive outcomes
  • More accurate insights for policymakers so they can make better informed decisions about public health issues


How ICD-10 Diagnosis Codes Can Help Your Revenue

ICD-10 may also mean good news for your revenue—provided you’re accurately and thoroughly documenting all you do for your patients.

Because diagnosis codes on the ICD-10 lists have greater granularity, they demand more detailed support in your notes and charts. See how these ICD-9 vs. ICD-10 examples call for different degrees of documentation:

  • ICD-9 had a single code (996.1) covering “Mechanical complication of other vascular device, implant and graft.” ICD-10 has 49 codes related to breakdowns, displacements, and leakages of heart-related equipment and grafts—codes like T82.312A (Breakdown (mechanical) of femoral arterial graft (bypass) and T82.525A (Displacement of umbrella device, initial encounter).
  • ICD-9 had five typhoid fever codes (002.0-.3, 002.9). ICD-10 has 11 codes for typhoid and typhoid and paratyphoid fevers (A01.00-.05, A01.09, A01.1-.4).
  • ICD-9 had nine location codes (707.00-707.09) for pressure ulcers. ICD-10 has 150 codes showing ulcers’ specific (not just broad) location and depth or stage (which ICD-9 codes didn’t address).

Despite the many new diagnosis codes payable by CMS and others in ICD-10, you’ll only be dealing with codes most relevant to your practice, as you were under ICD-9. And working with these codes, your error rate should drop because, as Sue Bowman reasons, ICD-10 is “less ambiguous and more logically organized and detailed.” Your lower error rate means you’ll see less risk of a medical coding audit, and your accounts receivable will see more reimbursement, faster.

Coding to the highest level of specificity with ICD-10 should also help you establish the medical necessity of the services you provide. Because medical necessity correlates to a visit’s complexity and risk, the greater the documented necessity, the higher the complexity/risk score, and the more complex your medical decision-making. Therefore, for many visits, you could potentially, legitimately submit higher CPT® codes (assuming you have completed the appropriate physical and history and have documented such), confident you can support the accompanying ICD-10 codes’ specificity.


Strengthen Your Overall Documentation and Revenue with MDCodePro

For all that’s changed with U.S. adoption of ICD-10, one thing hasn’t: Accurate documentation is still key to better patient care and stronger physician reimbursement.

As mentioned earlier, MDCodePro focuses on the other codes your charts and claims need: the CPT® codes. But the documentation essentials we teach in the app’s video lecture series will also help you capture the data you need to support the diagnosis codes CMS and other payers look for.

By supporting and submitting the best possible ICD-10 and CPT® codes, you’ll be ensuring you are appropriately paid for the services you provide. And Ambrose Bierce’s quip notwithstanding, you’ll know you’re serving your patients as their “pulse,” not their “purse,” deserves.

For more information about how MDCodePro can help you improve your documentation and your revenue, contact us using this easy online form.

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