What You Must Know About Medicare’s New ICD Guidelines

Find out Why Getting Your ICD-10-CM Codes Right Matters More Than Before

Mark Twain wrote, “The difference between the almost right word and the right word… [is] the difference between the lightning-bug and the lightning.”

Could we say the same about the difference between diagnostic codes?

The “grace period” during which CMS allowed less than full compliance with its official ICD-10 guidelines for Part B claims expired October 1, 2016. That means it’s been some time since you could settle for the “almost right” diagnostic code.

Simply using a valid code from the correct code “family” isn’t good enough. If you don’t code claims to the highest level of specificity your documentation supports, Medicare isn’t going to pay. Neither will commercial insurance payers who follow CMS’ lead. What’s more, your risk of facing a coding audit may go up.

Of course, regulatory compliance and audit avoidance aren’t the only reasons to pay close attention to official guidelines for coding with ICD-10. The greater accuracy the system makes possible can improve patient outcomes and provide valuable data for clinical researchers.

It can also increase your income. When you’re not losing revenue for a service you provide because an “almost right” diagnostic code won’t support it, your practice’s bottom line is bound to improve.

While the MDCodePro app will help you choose the optimal CPT® code for each patient visit, it also assumes your correct use and up-to-date knowledge of diagnostic codes. So reviewing recent diagnostic coding developments is important.

Here’s a brief rundown of notable ICD guideline changes introduced in 2018, along with a glimpse of some changes for 2019.


ICD-10 in 2018: Ulcers, Injuries and Suicides, Vehicle Morbidity, and Substance Abuse Remission

icd guidelinesWith the adoption of ICD-10 in the U.S. in 2015, diagnostic codes increased by 423%—from 13,000 in ICD-9 to about 68,000 in the new system. And since that time, the number of codes has only kept growing.

The ICD-10-CM guidelines for fiscal year 2018 added 363 new codes, revised 226, and deleted 142. (The “CM” suffix refers to Clinical Modification codes, as opposed to ICD-10-PCS, the Procedure Coding System that replaced ICD-9-CM Volume 3 codes.)

Chapter 12 of ICD-10, which deals with skin and subcutaneous tissue diseases, saw the most additions: 72 new codes, all describing “non-pressure chronic ulcers that involve muscle or bone without the presence of necrosis.”

Chapter 19, covering “Injury, poisoning, and certain other consequences of external causes,” was revised 300 times, but only received a dozen new codes, “all related to unspecified injuries and suicides.”

Other chapters with a significant number of new codes included chapter 7 (55 new codes related to diseases of the eye and its adjoining organs) and chapter 20 (54 codes identifying 3- or 4-wheeled ATVs and dirt bikes and motocross bikes as “external causes of morbidity”). And Health Leaders Media noted a change that allows physicians “to select a specific ICD-10-CM code when a patient is in remission from abuse of . . . alcohol, opioids, cannabis and nicotine,” among other substances.


ICD-10 in 2019: More Specific Locations, Multiple Gestations, and Newborn Complications

For FY 2019, ICD-10-CM has grown by 279 new codes, bringing the total number of codes to 71,701. That total also reflects 143 revised codes and 51 deleted codes.

Most of this year’s guideline changes in ICD-10 make the system’s very specific codes even more so, according to the AAPC’s Renee Dustman. She notes how “multiple new codes” take the place of deleted ones to communicate location as well as laterality—“right upper eyelid” instead of “right eyelid,” and so on. She also alludes to “a surprising number of new codes” in Chapters 7 and 19 (both of which underwent many changes in 2018 as well).

Chapters 15 (Pregnancy, Childbirth and the Puerperium) and 16 (Certain Conditions Originating in the Perinatal Period) also contain notable numbers of new codes. The 18 new codes in the former chapter deal with multiple gestations (like triplets and quadruplets). The 25 in the later cover complications “related to maternal drug use, metabolic disorders in the newborn, and newborns affected by the Zika Virus.”


MACRA Makes Getting ICD-10-CM Guidelines Right Count Even More

Choosing the right diagnostic code is key to submitting claims that conform to new Medicare guidelines regarding ICD-10. Just look at how the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) makes getting your coding correct even more important.

Under MACRA this year, 10% of a physician’s Merit-Based Incentive Payment System (MIPS) score is “Resource Use or Cost.” Your use of ICD-10 codes directly impacts your “Resource Use or Cost” score, which makes up 10% of your total Merit-Based Incentive Payment System (MIPS) score under MACRA. If your score is too low, you’re considered inefficient because it appears you’re spending too much to treat the diagnoses you’ve identified, and your reimbursement could be cut.

Beginning In 2019, the Resource Use/Cost score will account for 30% of your MIPS score. Now is the time to get your ICD-10 usage in order.


Make Sure You’re Meeting Medicare Regulations with Help from MDCodePro

While you’re working on your compliance with ICD guidelines, why not also make sure you’ve mastered CPT® coding essentials?

Through our intuitive and powerful app, MDCodePro offers you an easy education in medical coding basics and a Code Generator that returns the optimal CPT® code for each patient visit, based on the information you provide.

Sign up today for your MDCodePro subscription and start seeing how just the right CPT® codes, combined with the right ICD-10 codes, can ensure your claims satisfy CMS’ new Medicare guidelines. We’ll help you make the “lightning” of right rather than “almost right” coding strike your practice every day, sparking your improved accuracy, efficiency, and profitability.

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