ICD-10’s implementation on Oct. 1, 2013 will change everything from the way health care providers document services to the way codes are selected, reported, and reimbursed. It forces medical staff to see computers as partners rather than simple tools. The advent of ICD-10 will homogenize practices, requiring all who come in contact with patients and their records to adapt. Yet, it will be coders who set the keystone for success.

Preparation Is Key
Imagine how you’d prepare for an elderly relative’s move to your house. You’d be anxious, for sure, but preparation would override that as you made decisions about the physical changes the house requires and alterations to your routines. The new member of your household would bring stress, but housing her must be done. Ultimately, the experience would make you grow, and maybe even a newfound appreciation would form. That’s why AAPC is putting so much time into helping you prepare. “ICD-10 is not just about coding,” Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, AAPC’s vice president of ICD-10 education, recently told attendees at the annual meeting of the American Academy of Otolaryngologists. “It changes everything about your practice. If you don’t make the transition to ICD-10 on time, you won’t get paid. It’s that simple.”

ICD-10, with 78,797 new diagnostic codes, may seem overwhelming, but its elegance is impressive. For example, ICD-10 codes for diabetes are more specific, helping to identify the care needed. Ilio-sacral joint problems, previously reported as unspecified lower back pain, now can be specifically coded and care better tracked. New specificity found in the codes will help make documentation for pay-for-performance and quality tracking programs much easier, Buckholtz says. Every form, procedure, policy, contract, or program will be affected as each of these is tied to diagnostic coding.

All Eyes on Coders
Americans like to do things bigger and better. It’s no wonder, then, that even though we are one of the last countries to adopt ICD-10, our clinically modified version expands 79,000 codes laterally to seven characters rather than the usual five used by other countries. Our ICD-10 is big. It means physicians and other health care professionals must provide detailed documentation so you can code to the greatest specificity.

The expected advantages of electronic health records (EHRs) aside, all eyes will turn to coders to make sense of ICD-10-CM and ICD-10-PCS, Buckholtz tells Coding Edge. Central to success is a better understanding of anatomy and pathophysiology (A&P), Buckholtz says, cautioning even the savviest coders to strengthen their knowledge of A&P. The specificity of ICD-10 codes is based on a  precise identification of body sites and function. Not only will you need to know that, but you will also need to help your provider understand why detailed documentation is necessary, she says. AAPC provides a number of resources—Web-based, live, and printed—to help you lead your practice into this new way of managing the data and revenue of patient care. You can access information on ICD-10 implementation, 5010 electronic transaction standards, and other coding facets through a number of avenues.For the last two years and through this August, AAPC has been helping practices, payers, and facilities prepare for ICD-10 implementation. Beginning in September 2012, code set training will be everyone’s focus.

Training Steps to 2013
Buckholtz outlines a five-step process to ICD-10 implementation, which can be found at www.aapc.com on the ICD-10 tab. Here you will find explanations for the various training tools and a tracker to help you gauge your preparedness and get your practice ready. AAPC also offers to members a free ICD-9 to ICD-10 code conversion tool based on the Centers for Medicare & Medicaid Services’(CMS’) general equivalence mappings (GEMs) files. Simply enter an ICD-9 code to see the ICD-10 code(s) equivalent.

ICD-10 Implementation Training – AAPC offers a two day boot camp or on-site training for larger organizations, outlining all the steps and resources needed to switch to ICD-10-CM and ICD-10-PCS. These boot camps are held all over the country and attendees leave armed to prepare.

A&P – This 14-hour, online, advanced training will strengthen your A&P knowledge so you can feel confident in your ICD-10 code selection. This will help you earn up to 14 CEUs.

Clinical Requirements in ICD-10 – This online program will help your provider fine-tune documentation to meet the rigid standards ICD-10 will demand.

ICD-10-CM General Code Set Training – This code set and guidelines training begins in September this year with online or boot camp training. Hands-on exercise will help attendees feel more confident about the upcoming change as they become familiar with the new system. Training will be offered as workshops and online. Conferences in 2013 will include general code training.

ICD-10-CM Specialty Code Set Training – Beginning January 2013, specialty code set training will help coders see the impact ICD-10-CM will have in a particular setting. ICD-10 will, for example, affect cardiology differently from pediatrics.

Online Proficiency Prep Tool – Available in September, this online tool will help coders prepare for ICD-10 with case studies, practical exercises, and tips for passing their proficiency assessment.

Proficiency Assessment – Prove ICD-10 expertise to colleagues and providers by taking this 75-question exam before Sept. 30, 2014. Certified coders should complete this exam to maintain their status as elite coders.

More ICD-10 Resources
AAPC already offers and is developing several tools to make the transition easier.

ICD-10 Fast Forward – These inexpensive, laminated sheets include crosswalks from ICD-9-CM to ICD-10-CM for the top 50 diagnoses for 15 specialties. Learn of frequently-used codes in your specialty that will change, and use the cards to help develop new superbills and train others in your practice.

ICD-10 Code Books – AAPC will offer the final code set with guidelines you can use as a learning and documentation assessment tool beginning early 2012.

Local Chapter Training – Local chapters have two options: Easily accessed chapters can request a visit from a National Advisory Board (NAB) member or one of the AAPC Chapter Association (AAPCCA) Board of Directors members. For those where travel is difficult or who can’t wait, download an ICD-10-CM and ICD-10-PCS presentation from the local chapter page at www.aapc.com.

Webinars and Workshops – ICD-10-CM/PCS is part of AAPC’s regular educational fare. Take advantage of on demand webinars or the latest in on-demand workshops, such as November’s “ICD-10, What You Need to Know Now!” by Kim Reid, CPC, CPMA, CPC-I, CEMC. Free resources and costs for training can be found on www.aapc.com. According to Buckholtz, “AAPC is trying to provide as much I-10 support and training in the most affordable, effective, and accessible ways possible. We want our members to be the leaders in I-10 adoption at their workplaces because nobody can code like an AAPC member.”

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Computed tomography (CT) uses computer imaging and multiple, narrow beams of X-rays to produce thin, cross-sectional views or images of various body layers. These images allow visualization of soft tissue, as well as bones, making them useful for evaluating a wide range of conditions.

 CT imaging of the abdomen and pelvis frequently are performed together during the same encounter. The combined services are useful for evaluating a large number of conditions, including abdominal and pelvic pain; infections such as appendicitis or diverticulitis; inflammatory processes such as ulcerative colitis; and cancers of the colon, liver, kidneys, pancreas, and bladder. Combined CTs of the abdomen and pelvis also are performed to quickly identify internal injuries in cases of trauma.

During CT of the abdomen, the organs visualized include: the liver, spleen, kidneys, pancreas, the top half of the large intestine, the small intestine, and the superior aspect of the ureters. During a CT of the pelvis, the organs visualized include: the remainder of the large intestine, the small intestine, and ureters, as well as the bladder, uterus, and ovaries.

Combined Services Call for New CPT^® Codes

Prior to 2011, two CPT^® codes had to be selected to reflect the combined services when CTs of both the abdomen and pelvis were taken during the same encounter. Because of an increased frequency of these services performed during the same encounter, the American Medical Association (AMA) developed three new CPT^® codes for 2011 that reflect current practice.

Use these codes for a CT of the abdomen alone:

74150      Computed tomography, abdomen; without contrast material

74160      Computed tomography, abdomen; with contrast material(s)

74170      Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections 

Use these codes for a CT of the pelvis alone:

72192      Computed tomography, pelvis; without contrast material

72193      Computed tomography, pelvis; with contrast material(s)

72194      Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections

The following codes should be used only if both the abdominal and pelvic CT are performed during the same encounter.

74176      Computed tomography, abdomen and pelvis; without contrast material

74177      Computed tomography, abdomen and pelvis; with contrast material

74178      Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions

The AMA includes a table in CPT^® 2011 (see Table A) to help you determine the correct code.

Table A

Table A illustrates that CPT^® 74176 should be used only if both studies are done without contrast. Use CPT^® 74177 only if both studies are done with contrast.

Code 74178 should be used in two situations:

• One or both studies are done without contrast, followed by contrast material(s) and further sections.
• One study is done without contrast, while the other study is done with contrast.

Scenarios Help Show Correct Coding

Example one: A 34-year-old male presents with 48 hours of lower abdominal and pelvic pain. The patient also has a low-grade temperature. His physician orders a CT of the abdomen and pelvis without intravenous contrast. The radiologist supervises the process of providing the CT, and then interprets the images acquired. He also dictates a report of his findings. The radiologist should report 74176.

Example two: A 48-year-old female presents with flank pain and persistent gross hematuria. The patient’s urologist conducts a cystoscopy and is unable to identify the cause of the patient’s symptoms. He orders a CT of the abdomen and pelvis without and with intravenous contrast. The radiologist supervises the process of providing the CT, and then interprets the images acquired. He also dictates a report of his findings. The radiologist should report 74178.

Coding tips to remember:

• If both a CT of the abdomen and a CT of the pelvis are performed during the same session, use one of the new codes that describes that combination of services (74176, 74177, and 74178).
• Refer to the table provided in the CPT^® book to determine the correct code.
• Report 74176, 74177, or 74178 only once per session.
• Codes 74176, 74177, and 74178 can never be reported together with any of the codes for CT of the abdomen alone (74150, 74160, and 74170), or CT of the pelvis alone (72192, 72193, and 72194).

Nancy Higgins, CPC, CPC-I, CIRCC, CPMA, CEMC, has over 20 years of experience in the health care industry and is a manager in the Corporate Compliance department at Carolinas Healthcare System in Charlotte, N.C. Nancy is past president of the Charlotte, N.C. Local AAPC Chapter and was AAPC’s 2009 Coder of the Year. She can be reached at nancy.higginscpc@yahoo.com.

By Sara Wolf, BA, CPC-H, CCS, and G. J. Verhovshek, MA, CPC

Deep vein thrombosis or deep venous thrombosis (DVT) describes the formation of a blood clot (thrombus) in a “deep” vein. The condition is most common in the large veins of the lower extremities (for example, the femoral vein), but may occur in veins of the upper extremities, as well.

DVT may be asymptomatic, but more frequently exhibits symptoms of pain, swelling, and discoloration in the affected extremity. Three broad mechanisms—called “Virchow’s triad” in honor of German physician Rudolf Virchow—are the primary causes of DVT:

1. Decreased blood flow

2. Damage to the wall of the vein

3. Increased blood clotting (hypercoagulability)

Many specific circumstances may contribute to the formation of DVT. Recent surgery—especially hip, pelvic, or prostate surgery—is a risk factor (See “DVT Linked to Surgery Calls for Unique Coding” for more information.), as is inactivity, obesity, smoking, a history of cardiovascular disease, or other medical conditions ranging from cancer to bone fracture. Women who are pregnant or who have been pregnant recently are more prone to DVT, as are those who use estrogen or oral contraceptives.

Verify Criteria to Determine Codes

ICD-9-CM groups DVT by two criteria: vein location and chronic vs. acute. The determination of chronic vs. acute must be made by the documenting provider, based on the clinical evidence. For example, the diameter of a vein as measured by duplex scan may increase in acute conditions, but will decrease to less than normal over time.

Chronic vs. Acute: Make the Distinction

Here are the acute and chronic DVT codes for upper and lower extremities:

DVT Lower Extremities

• Acute: femoral, iliac, popliteal, and vein of thigh or upper leg not otherwise specified (453.41 Acute venous embolism and thrombosis of deep vessels of proximal lower extremity)
• Acute: peroneal, tibial, and vein of calf or lower leg not otherwise specified (453.42 Acute venous embolism and thrombosis of deep vessels of distal lower extremity)
• Acute: unspecified vein of lower extremity and DVT not otherwise specified (453.40 Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity)
• Chronic: femoral, iliac, popliteal, and vein of thigh or upper leg not otherwise specified (453.51 Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity)
• Chronic: peroneal, tibial, and vein of calf or lower leg not otherwise specified (453.52 Chronic venous embolism and thrombosis of deep vessels of distal lower extremity)
• Chronic: unspecified vein of lower extremity (453.50 Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity)

DVT Upper Extremities

• Acute: brachial, radial, and ulnar vein (453.82 Acute venous embolism and thrombosis of deep veins of upper extremity)
• Chronic: brachial, radial, and ulnar vein (453.72 Chronic venous embolism and thrombosis of deep veins of upper extremity)

Note that the default code for DVT of an unspecified site is 453.40. ICD-9-CM also contains codes to report embolism/thrombosis of superficial and/or other specified (not deep) veins (e.g., 453.6 Venous embolism and thrombosis of superficial vessels of lower extremity and 453.76 Chronic venous embolism and thrombosis of internal jugular veins).

The distinction between acute and chronic is important because patients with DVT may require anticoagulant therapy for six months or more; an acute diagnosis would support initiation of such therapy, while a chronic diagnosis would support its continuation. Code V58.61 Long term (current) use of anticoagulants may be reported in addition to the code describing the DVT if the patient currently is undergoing anticoagulant therapy.

If a patient has a history of venous thrombosis that is no longer present, you may assign personal history code V12.51 Personal history of venous thrombosis and embolism, pulmonary embolism.

PE Complicates DVT and Coding

An embolism occurs when a thrombus dislodges and is carried by the circulatory system to a different part of the body. The clot travels through progressively smaller vessels until it becomes stuck in place. An embolism resulting from DVT most often affects vessels of the lungs after traveling through the heart. This is called a pulmonary embolism (PE), and it may result in labored breathing, chest pains, and even death.

An acute PE may be reported from ICD-9-CM category 415.1x Pulmonary embolism and infarction. Note that septic pulmonary embolism code (415.12 Septic pulmonary embolism) requires you to sequence the underlying infection before the PE code. Chronic PE is reported using 416.2 Chronic pulmonary embolism.

 Sara Wolf, BA, CPC-H, CCS, has nearly 30 years of coding experience. She is executive director for ZHealth, providing coding consulting and reimbursement evaluation for facility and physician services.

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

By Lisa Jensen, MHBL, FACMPE, CPC

According to the April 2011 Parents Magazine, 40 percent of school age children are behind on their vaccines. Measles, mumps, whooping cough, and other diseases once nearly eradicated in the United States are again on the rise. The culprit is thought to be a loss of faith in the safety and efficacy of vaccines. News headlines and Internet chatter warn of vaccines leading to autism, asthma, attention deficit hyperactivity disorder (ADHD), diabetes, etc. On the other side of the debate are many studies pointing to evidence that vaccines and their components are safe and effective.

Parents trying to determine what is best for their child often turn to the child’s pediatrician or other health care provider for advice. With all the conflicting information to sift through, providers often must spend a lot of time counseling parents prior to administering vaccines. Complete, proper coding ensures this time is fairly reimbursed.

Vaccine Timing Is Important

Each year, based on the most recent scientific data, disease experts recommend a vaccine schedule to best protect children in the United States. Changes, if needed, are announced in January. The schedule is approved by the American Academy of Pediatrics (AAP), the Centers for Disease Control and Prevention (CDC), and the American Academy of Family Physicians (AAFP).

The recommended vaccine schedule is influenced by several age-specific factors, such as risks for disease and complications, responses to vaccination, and potential interference with the immune system by passively transferred maternal antibodies. Taking these factors into account, vaccinations are scheduled for the earliest age group for which efficacy and safety have been demonstrated.

For many vaccines, three or four doses are needed to fully protect a child. To work best, the doses need to be spaced out. Although the vaccine schedule is considered ideal, there are exceptions for some children, including those who have an allergic reaction to an ingredient in the vaccine, a weakened immune system due to illness, a chronic condition, or are undergoing another medical treatment.

Code Administration in Two Parts

The services associated with administration of vaccines are coded and billed in two parts: one code for the vaccine and another for the administration. You must report both parts of the service to ensure accurate coding and reimbursement.

For 2011, the American Medical Association (AMA) introduced two new codes in CPT® for vaccine administration:

90460      Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component

+90461    Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component (List separately in addition to code for primary procedure)

The new codes differ from the previous (now deleted) codes 90465-90468 in several ways. Most importantly, the previous codes were reported per immunization, whereas the new codes require you to report each component separately. A component refers to all antigens in a vaccine that prevent disease(s) caused by one organism. Combination vaccines are those that contain multiple vaccine components.

The table below shows the differences between the old and new administration codes.

These changes mean that vaccine administration coding will look very different than it has in the past. More claim lines will be required to report the same services, and counting the number of components will be different now when we count vaccines. For example:

• HPV vaccine would be one component and coded as 90460
• Td would be two components and coded as 90460, 90461
• DTaP or Tdap would be three components (90460, 90461, 90461)
• DTaP-Hib would be four components (90460, 90461, 90461, 90461)
• DTaP-Hib-IPV would be five components (90460, 90461, 90461, 90461, 90461)

Counseling Is Critical

Counseling by a physician or other qualified health care professional (e.g., physician assistant or nurse practitioner) at the time of the administration is critical and a requirement of 90460 and 90461. Let’s define counseling.

CPT® requires each service billed to be fully and independently supported by medical record documentation, but does not go into specific detail about exact requirements to support the counseling of each component. Providers must provide face-to-face counseling, and then choose the format that works for them and their clinic, while still making it crystal clear which vaccine components were counseled on, and what that entailed.

For example, a note might include all vaccine components recommended at this visit, a notation that each component had counseling, and any issues discussed specific to those patient risk factors.

The documentation should support the time and effort associated with administering combination vaccines. Photocopying a statement, stamping a statement, or cutting and pasting templated documentation should be avoided. If you are concerned about your specific templates or documentation format, check with your payers to see what their payment policies are surrounding these new codes.

Some Administration Codes Carry Over

Vaccine administration codes 90471-90474 carry over from previous years, to be used for patients 19 years and older when the provider does not provide counseling, or if the health care professional providing the counseling does not meet state requirements for an “other qualified health care professional.”

90471      Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

+90472    Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

90473      Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)

+90474    Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

Counseling and Non-counseling Codes Can Be Mixed

If counseling is provided for some, but not all, vaccine/toxoid components to be administered, new administration/counseling codes 90460-90461 and carry-over administration codes 90471-90474 may be reported together to accurately reflect the services rendered. For example, if counseling is performed for HPV vaccine but not for an influenza vaccine provided at the same visit, report 90460 for the HPV and 90472 (or 90474, if the second, non-counseled vaccine is administered orally or intranasally) for the influenza vaccine.

Another circumstance might occur if counseling was provided at an earlier visit, the parent has new questions or concerns at the return visit, and the physician or other qualified health care professional is asked to address these concerns. It would be appropriate to report code 90460 at the administration of a series vaccine if counseling is clearly documented during a return visit.

As a complete coding example (including administration and vaccine reporting), consider the following case:

A patient presents for her two-month well-child visit and is vaccinated for DTaP-Hib-IPV (Pentacel), pneumococcal, and rotavirus.

With the discussion of childhood vaccines becoming so much more challenging, use of new codes 90460 and 90461 to adequately report and represent the complexity of these services is very important. It is clear with the increase of preventable illness in children that the role of the vaccines is still essential to ensuring the health of our communities, and coding these correctly is important to supporting this effort.

Lisa Jensen, MHBL, FACMPE, CPC, is the manager of external audits for Providence Health Plans in Beaverton, Ore. Ms. Jensen has a master’s in healthcare business leadership and an undergraduate degree in psychology with an emphasis in behavioral modification. She has spent much of the 19 years of her health care career managing teams and educating colleagues on coding, revenue cycle improvement, and compliance. Her health care experiences include physician clinics, group practices, a teaching hospital, health care consulting, and a health plan.