What You Must Know About New Medicare Guidelines and ICD-10

Find out why getting your ICD-10 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?

CMS’ “grace period” for implementing new Medicare guidelines for Part B claims coded with ICD-10 expired October 1, 2016. You can’t settle for “almost right” codes anymore; simply using a valid code from the correct ICD-10 code “family” isn’t good enough. You must code claims to the highest level of specificity your documentation supports, or those claims will be rejected by Medicare plans (not to mention some other payers)—and your risk of a medical coding audit may go up.

But regulatory compliance and audit avoidance aren’t the only reasons to use the right codes instead of “almost right” ones.

Think about greater accuracy in patient records, which contributes to improved outcomes. Or consider research benefits: As Dr. Richard Pinson points out for ACP Hospitalist, the detail captured in ICD-10 coded clinical data “will permit more comprehensive analysis of valuable clinical information.” And don’t forget the boost to your practice’s bottom line when you’re not losing revenue for your work because a broader diagnostic code didn’t support it

MDCodePro helps you choose the optimal CPT® code every time, but of course every claim you submit must include a diagnostic code as well as conform to CMS guidelines for billing. Our methodology assumes your knowledge and correct use of diagnostic codes. ICD codes can change with each fiscal year, so reviewing recent diagnostic coding developments is important. Here’s a brief overview of notable ICD-10 changes in 2018, along with a glimpse of what 2019 may bring.

What’s New in ICD-10 for 2018 and 2019?

New-Medicare-Guidelines ICD-10 had already increased the number of diagnostic codes by 423%—from 13,000 in ICD-9 to about 68,000—but fiscal year 2018 still saw 360 new codes, along with 226 revised ones, according to coding publisher Optum 360°.

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 include chapter 7 (55 new codes related to diseases of the eye and adnexa) 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 notes a change allowing 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.

As of this writing, changes for fiscal year 2019 are still in development. ICD10monitor has identified several proposals that might be incorporated as of October 1, 2018, including codes related to acne vulgaris, drowning in natural bodies of water, heatstroke brought on by strenuous activity, immunocompromised status, the ingestion of multiple unknown drugs, traumatic brain herniation, and more.

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

Choosing the right ICD-10 code is critical for submitting claims that conform to the new Medicare guidelines. And 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 and CPT® codes directly impacts this score. As the Medical Association of Alabama explains, Medicare expects “a patient with a certain diagnosis will incur an estimated cost. If the cost to treat the patient far exceeds the estimate, then the physician’s Resource Use/Cost score will be low.” If your score is too low, you are considered inefficient and your reimbursement could be cut.

In 2019 and later, the Resource Use/Cost score will account for 30% of your MIPS score, so now is the time to get your ICD-10 usage in order. And while you’re doing that, why not make sure you’ve mastered CPT® coding essentials, too? Through our intuitive 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 and make the “lightning” of improved information, efficiency, and income consistently strike your practice.

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