Coding to Highest Specificity ICD-9 CM

1. Coding to Highest SpecificityICD-9 CM Why it is important and how it affects you as a physician. Jeni Smith, CPC

2. The Major Issues • Quality Report Suffers • It will not paint an accurate picture of the severity of the illnesses • Severity of illness is a measure of the patient's overall health status reflected by the resources necessary for care and the risk of morbidity and mortality • “severity of illness is understated 8%-15% of the time. Mortality is understated 15%-25% of the time.” (For the Record, page 11) • Reporting comorbidities and illness severity will help better define quality of care and medical necessity for that care.

3. The Major Issues Continued • RAC Audits • 85% of Medicare RAC audit identified overpayments have been directly related to coding, determination of medical necessity and/or a need to enhance detailed documentation gathered in support of submitted claims. • RAC took back over $900 Million from hospitals (Took 3 Mil. from AGH) • More MCC, can lead to increased level of visit • Increases in morbidity, mortality, and length of stay will not correlate with the documented severity of illness which could lead to red flags

4. Major Issues Continued • Transfer to ICD-10 System Inevitable • ICD-10 offers more detailed information and the ability to expand specificity • Greater specificity and clinical information, which results in: • Improved ability to measure health care services • Increased sensitivity when refining grouping and reimbursement methodologies

5. How to Code for Specificity • A code is invalid if it has not been coded to the full number of digits required for that code. • Provider reports the full ICD-9-CM • ICD-9 codes may have three to five digits depending on their category. • Each digit provides important information about the patient's condition. http://www.aafp.org/fpm/990700fm/27.html

6. ExamplesChronic Kidney Disease (CKD)

7. Examples ContinuedDiabetes 250.13, uncontrolled type 1 diabetes with ketoacidosis. Choosing the most specific code means coding only what you know to be a fact. • The three-digit code (in this case, 250) represents the diagnostic category. • The fourth digit identifies complications associated with diabetes • The fifth digit describes the type of diabetes and its level of control. To correctly code an encounter with a patient who has uncontrolled type 1 diabetes complicated by ketoacidosis, you should use all five digits.

8. Examples ContinuedHypertension • Patient, follow-up of benign essential hypertension = 401.1 (The fourth digit identifies the disease as benign and thus is the most specific description of your patient's condition) • However, patient also has benign hypertensive heart disease, include a fifth digit = 402.10 or 402.11 (depending on the absence or presence, respectively, of congestive heart failure) http://www.aafp.org/fpm/990700fm/27.html

9. Conclusion • You must always code to the highest number of digits that best describe your patient's condition • Physicians are legally responsible for the codes selected and submitted to payers. • Coding to the highest specificity allows for more accurate report of quality of care and will prepare you for possible RAC audits and the implementation of ICD-10-CM.

10. Additional Diagnosis to watch • Heart Failure – Systolic or Diastolic • COPD – Need to state acute exacerbation • Sepsis – If code as 599.0, translates to UTI -Need to state Sepsis due to UTI • CVA – State with Residual or presenting symptoms • Anemia – Chronic, Acute blood loss, iron deficiency • Pneumonia – Which Bacteria • DM – Need type and whether controlled/uncontrolled • Morbid Obesity – Must state BMI, can increase reimbursement by thousands (Already calculated on MAR)