Coding Category

ICD-10 Delay

CMS LogoPresident Obama signed the bill into law Tuesday morning, officially shifting the deadline for ICD-10 compliance from October 1, 2014 to no earlier than October 1, 2015. AAPC remains dedicated to helping the industry prepare for ICD-10 implementation.

Thanks again for your continued commitment and involvement. Additional details will be forthcoming.

April 3rd, 2014

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New Technology Advances Bariatric Surgery

For more precise coding, understand underlying causes, anatomy, and new treatment options for obesity. 

By Laurette Pitman, RN, CPC-H, CGIC, CCS

Obesity has become a public health concern in the United States. In 2012, 26.2 percent of Americans were considered to be obese; of this population, 4 percent were considered to be morbidly obese.

Body mass index (BMI) is the primary measurement used to classify obese patients. In 1991, the National Institutes of Health provided the following definitions:

Category Body Mass Index (kg/m2) Over Ideal Body Weight (%)
Overweight 25.0 – 29.9  
Obesity (class 1) 30 – 34.9 >20%
Severe obesity (class 2) 35 – 39.9 >100%
Severe obesity (class 3) 40 – 49.9  
Superobesity >50 >250%

Factors, Associated Conditions, and Non-surgical Treatment

Simply put, obesity occurs when a person takes in more calories than he or she burns through exercise and normal daily activities. The body stores the excess calories as fat. Additional factors that may contribute to the development of obesity include:

  • Inactivity
  • Unhealthy diet and eating habits
  • Pregnancy
  • Lack of sleep
  • Certain medications
  • Medical problems (Prader-Willi syndrome, Cushing’s syndrome, polycystic ovary syndrome, hypothyroidism)

There are more than 30 co-morbid conditions associated with severe obesity. According to information from the Cleveland Clinic, the most common of these is insulin resistance and diabetes mellitus, which occur in 15-25 percent of obese patients. Other common obesity-related conditions include hypertension, heart disease, cancer, osteoarthritis of weight bearing joints, sleep apnea, respiratory problems, gastroesophageal reflux disease, depression, infertility, and urinary stress incontinence.

Obesity treatment may start with counseling on diet, exercise, and lifestyle modifications. In patients who fail to achieve weight loss goals through diet and exercise alone, or who have significant co-morbidities, pharmacologic therapy may be added.

Multiple drugs now on the market may be prescribed for appetite suppression. All have side effects. The choice of drug is usually dependent on the patient’s ability to tolerate those side effects. According to the Cleveland Clinic, the amount of weight loss achieved through pharmacologic therapy is generally modest (< 5 kg at one year).

Surgical Intervention

In recent years, we have seen surgical options for morbid obesity become more common. Patients with a BMI >35 kg/m2 with obesity-related co-morbidities, and those with a BMI >40 kg/m2 with or without co-morbidities, are eligible for bariatric surgery. Other criteria for surgical candidacy include:

  • • Acceptable operative risk
  • • Documented failure of nonsurgical weight loss programs
  • • Psychologically stable, with realistic expectations
  • • Well-informed and motivated patient
  • • Supportive family and social environment
  • • Absence of active alcohol or substance abuse
  • • Absence of uncontrolled psychotic or depressive disorder

The National Institutes of Health guidelines recommend bariatric surgery to be limited to patients 18-60 years old.

The most commonly performed bariatric procedures are the Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and the sleeve gastrectomy. All of these procedures have a CPT® Category I code available for assignment when these surgeries are performed. Because coverage guidelines for each procedure vary by payer, you must know these individual guidelines to bill appropriately and receive reimbursement.

Roux-en-Y Gastric Bypass

The Roux-en-Y gastric bypass combines a restrictive component and a limited proximal intestinal bypass, and is the most common bariatric procedure performed in the United States. This procedure can be performed by open or laparoscopic techniques, with the laparoscopic procedure resulting in a faster recovery and fewer complications.

A small, 15 to 30 mL gastric pouch is created to restrict food intake, and a Roux-en-Y anastomosis bypasses the duodenum and proximal jejunum. This procedure has been found to result in superior weight loss and co-morbidity resolution.

CPT® codes for this procedure are 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy and 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy.

Adjustable Lap Band

The laparoscopic adjustable gastric band has been approved for use in the United States since 2001. A silicone band with an inflatable inner collar is placed around the upper portion of the stomach to create a small gastric pouch, and to restrict the gastric cardia. The band is connected to a port that is placed in the subcutaneous tissue of the abdominal wall. The inner diameter of the band can be adjusted by injecting saline through the port.

The Category I CPT® code for insertion of the lap band is 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components). Several codes are available for the removal, revision, and replacement of the device.

Laparoscopic Sleeve Gastrectomy

The laparoscopic sleeve gastrectomy has been in use as a bariatric procedure for approximately 10 years. This procedure involves a vertical resection and removal of the body and fundus of the stomach, which leaves a tubular gastric lumen from the gastroesophageal junction to the antrum. The pylorus is left intact and no device is implanted nor bypass performed.

This procedure is reported with 43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy).

Vagus Nerve Blocks

Medical science is constantly searching for newer, better, and less invasive means of treating diseases such as obesity. One method being investigated is vagus nerve blocking therapy, which uses high frequency, small electrical pulses to block the transmission of the vagal nerve signals to the brain.

The vagus nerve is the longest cranial nerve, containing motor and sensory fibers, and has the widest distribution in the body. The gastric branches of the vagus nerve supply the stomach and play a significant role in food processing, and in signaling the feeling of fullness and prolonging the absence of hunger.

Studies have shown that patients who undergo surgical vagotomy commonly experience weight loss. In some cases, the effects were found to be temporary, as the body is usually able to compensate for the anatomical disruption by regulating to normal function. Consequently, a technique for intermittent blocking of the vagus nerve by laparoscopically implanted electrodes (which prevent the nervous system and digestive organs from compensating for changes in bodily functions) was developed for potential management of obesity.

The procedure involves a laparoscopic approach, where the physician makes three to five, 1 cm incisions to implant the electrodes. Through the smaller incisions, the physician inserts small electrodes around the vagus nerve near the distal esophagus. A neuroregulator is then placed under the skin, at a location selected by the physician in collaboration with the patient.

Two weeks after completion of the surgical procedure, the vagal blocking therapy is initiated in the physician’s office with programming of the neuroregulator. Patients may eat normal foods as part of a sensible diet with this device.

The potential benefit to the vagal nerve blocking system is that it does not alter the patient’s gastric anatomy and can be performed on an outpatient basis with regulation of the blocking system in the physician’s office, or with wireless communication technology.

This procedure/therapy is not approved in the United States. Clinical trials are now being performed by EnteroMedics® in the ReCharge Study as part of the U.S. Food and Drug Administration premarket approval process. The device developed by EnteroMedics® is called the Maestro® Rechargeable System.

Call on Category III for Vagal Nerve Blocking Systems

There are no CPT® Category I codes available for this new technology yet; however, CPT® does provide a set of temporary (Category III) codes for emerging technology, services, and procedures. If a Category III code is available for reporting a new procedure, it must be used rather than the Category I unlisted procedure code.

The Category III codes 0312T-0317T are to be used to report the laparoscopic vagus nerve blocking therapy for the treatment of morbid obesity (see the accompanying sidebar, “Category III Code Descriptions,” for the full descriptions). The services identified by these codes include:

  • Laparoscopic implantation of the neurostimulator electrode array and pulse generator (0312T)
  • Revision or replacement of the neurostimulator array with connection to existing generator (0313T)
  • Removal of the neurostimulator electrode array and pulse generator together (0314T)
  • Removal of the pulse generator independent of the electrode array (0315T)
  • Replacement of the pulse generator (0316T)
  • Electronic analysis of the pulse generator with reprogramming, if performed (0317T)

The Category III codes for the vagus nerve blocking procedure are scheduled to sunset in January 2018. If this procedure is performed after the archiving of the Category III codes without Category I codes assigned to replace them, it would be necessary to use appropriate unlisted procedure codes.

With the increasing incidence of obesity seen by medical practitioners, you can expect in the future to see other new technologies and treatments geared toward this and other associated co-morbid diseases. As coding professionals, you should be aware of all new Category III codes, as well as the coverage implications that are associated with any new treatments or procedures.


Laurette Pitman, RN, CPC-H, CGIC, CCS, is a senior outpatient consultant for SPi Healthcare. She has over 30 years’ experience in the healthcare field, including ED and OR nursing, coding, and DRG and APC auditing. Pitman is also an ICD-10-CM/PCS trainer and a member of the Lafayette, La., local chapter. For more information, please reference or email her at


April 1st, 2014

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Coding Acute Conditions: Eliminate Chronic Concerns

Accurate ICD-10 coding requires proper documentation and an understanding of clinical conditions.

By Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD

Coding acute conditions in ICD-10-CM can be tricky for a few reasons: For starters, the term “acute” has various meanings in the diagnosis code set. Second, there are timeframe factors to consider. And, third, there’s a new concept of acute recurrent conditions. To help clear up any coding confusion you may have, first consider Merriam-Webster’s definition of acute:

(1): characterized by sharpness or severity, “acute pain” (2): having a sudden onset, sharp rise, and short course, “acute disease” (3): being, providing, or requiring short-term medical care (as for serious illness or traumatic injury) “acute hospitals” “an acute patient.”

Next, consider acute condition criteria and look at a few telling examples, as follows.

Myocardial Infarctions (MI)

Coronary arteries are a network of arteries that supply blood to the heart muscle. The left main coronary artery and the right coronary artery stem from the aorta. The left main coronary artery bifurcates into the left circumflex and left anterior descending arteries, supplying blood to the left ventricle. The right coronary artery branches into the right marginal artery and posterior descending artery, supplying blood to the right ventricle.

Coronary artery disease is the result of the accumulation of atheromatous plaque within the walls of the coronary arteries. If blood flow is blocked long enough, a portion of the heart muscle is damaged or dies. This is an MI, or heart attack. More than a million people in the United States each year suffer MIs. The site of the MI will reflect the coronary artery experiencing the ischemia. For example, an MI of the anterior wall is caused by ischemia in the left anterior descending coronary artery.

ST elevation myocardial infarction (STEMI) occurs when there is a transmural infarction of the myocardium, which means the entire thickness of the myocardium (endocardium, myocardium, and pericardium) has undergone necrosis. This results in ST elevation on an electrocardiogram (ECG).

Non-ST elevation myocardial infarction (NSTEMI) occurs when there is a partial dynamic block to coronary arteries. There will be no ST elevation or Q waves on the ECG because transmural infarction is not seen.

According to ICD-10-CM, an MI is considered acute (AMI) when it’s specified as acute or is stated to persist four weeks (28 days) or less from onset. In this case, acute is tied to the duration.

Example 1: A patient presents to the clinic. Per documentation, the patient is here for a hospital follow up for an MI of the left anterior descending artery.

Without MI timing information, you’ll need to query the provider to assign the correct ICD-10-CM code. From an ICD-10-CM standpoint, if the MI occurred within 28 days, it’s acute.

There are no codes for chronic symptomatic MI in ICD-10-CM. If the patient is still symptomatic after 28 days, the guidelines (I.C.9.e.1) state that the appropriate aftercare code should be assigned. It’s imperative for the physician or other provider to understand the importance of documenting the timeframe and for the coder to understand how to use that information for coding purposes.

Example 2: A patient presents to the clinic. Per documentation, the patient is here for hospital follow-up for an MI of the left anterior descending artery suffered 10 days prior. The patient is still symptomatic.

In this example, there is sufficient information to support assignment of code I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery.

Heart Failure

Congestive heart failure describes a condition in which the heart isn’t able to pump enough blood to meet a body’s needs. This may happen when the heart muscle is weaker than normal, or when there is a defect in the heart that prevents blood from circulating. When the heart doesn’t circulate blood normally, the kidneys receive less blood. The kidneys then filter less fluid out of circulation into urine. The extra fluid in circulation builds up in the lungs, the liver, around the eyes, and sometimes in the legs. This is called fluid “congestion;” thus, the condition “congestive heart failure.”

Heart failure can be systolic, diastolic, or combined systolic and diastolic:

  • When the left ventricle can’t contract enough, it’s systolic heart failure.
  • When the left ventricle can’t fill with enough blood, it’s diastolic heart failure.

Heart failure can also be acute, chronic, or acute on chronic. In this case, acute heart failure is heart failure that happens when there has been sudden damage to the heart—for example, due to an MI, thrombus in the heart, or severe infection. Acute heart failure is life threatening.

Chronic heart failure happens slowly and is typically due to an underlying condition, such as hypertension or heart disease. Acute on chronic is seen when a patient has chronic heart failure and suffers an acute exacerbation.

Example: A patient presents to the emergency department with no prior cardiac history and no chronic diseases. He is found to have suffered an AMI and to be in systolic heart failure due to the AMI.

In this case, the documentation stating that the heart failure is brought on by the sudden MI renders the diagnosis acute systolic heart failure, indicated by ICD-10-CM code I50.21 Acute systolic (congestive) heart failure.


Asthma is a chronic lung disease that inflames and narrows the airways. People with asthma experience symptoms when the airways tighten, inflame, or fill with mucus. According to the American Lung Association, asthma is one of the most common chronic disorders in childhood, with an estimated 7.1 million children under 18 years of age affected. It’s the leading cause of absenteeism from school.

Common asthma symptoms include:

  • Coughing, especially at night
  • Wheezing
  • Shortness of breath
  • Chest tightness, pain, or pressure

Asthma is categorized by severity:

  • Mild intermittent: The patient is symptomatic two or fewer days per week, awakens at night two times or fewer per month, uses a rescue inhaler two or fewer days per week, has no interference with normal activity, and has greater than 80 percent predicted lung functions and normal lung function between exacerbations.
  • Mild persistent: The patient is symptomatic more than two days per week; awakens at night three to four times per month; uses a rescue inhaler more than two days per week, but not daily; has minor limitation with normal activity; and has greater than 80 percent predicted lung function.
  • Moderate persistent: The patient is symptomatic daily; awakens at night more than once per week, but not nightly; uses a rescue inhaler daily; has some limitation with normal activity; and has 60-80 percent predicted lung functions.
  • Severe persistent: The patient is symptomatic throughout the day; awakens nightly; uses a rescue inhaler several times per day; has extreme limitations with normal activity; and has less than 60 percent predicted lung functions.

Asthma is also categorized by complication:

  • Without complications
  • With acute exacerbation
  • With status asthmaticus

According to ICD-10-CM guidelines (I.C.10.a.1), an acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, although an exacerbation may be triggered by an infection. Status asthmaticus is an acute exacerbation of asthma that remains unresponsive to initial treatment with bronchodilators.

Example: An asthmatic patient presents for a check-up. The patient states that she uses her rescue inhaler daily; her asthma awakens her a few nights per week; and she has some limitations to normal activities. She has been coughing and running a fever. She is found to have pneumonia.

This case is not asthma in acute exacerbation, but moderate persistent asthma with pneumonia—a chronic condition with the pneumonia superimposed. There is no indication of a sudden worsening of the asthma itself.

It All Comes Down to Proper Documentation

It’s important to review these issues with your physicians and other providers to ensure documentation in the medical record supports the more specific code assignment possibilities in ICD-10-CM. You must also understand the differences in verbiage in ICD-10-CM to assign the correct codes. Working in cooperation with your peers will allow you to piece together the ICD-10-CM puzzle.


Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD, is director of ICD-10 Development and Training at AAPC and a member of the Frankfort, Ill., local chapter.

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CPT® 2014 Groups Drainage Codes with S&I

Familiarize yourself with new image-guided percutaneous fluid collection drainage codes, understand the rules, and apply them to scenarios.

By Terri Brame, MBA, CHC, CPC, CPC-H, CPC-I, CGSC

A review led by the American Medical Association’s CPT® Editorial Panel last year showed that codes for the surgical portion of percutaneous fluid drainage procedures were being reported with the codes for imaging supervision and interpretation (S&I) more than 75 percent of the time. Based on this review, the consensus reached was that a single code representing both services may be more appropriate. As a result, CPT® 2014 brings major changes for reporting percutaneous fluid drainage by catheter.

Many Changes to 2014 Coding

Several drainage codes were deleted for CPT®2014 and replaced by only a handful of new, more inclusive codes.

Deleted CPT® codes, effective Jan. 1, 2014:

32201  Pneumonostomy; with percutaneous drainage of abscess or cyst

44901  Incision and drainage of appendiceal abscess; percutaneous

47011  Hepatotomy; for percutaneous drainage of abscess or cyst, 1 or 2 stages

48511  External drainage, pseudocyst of pancreas; percutaneous

49021  Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; percutaneous

49041  Drainage of subdiaphragmatic or subphrenic abscess; percutaneous

49061  Drainage of retroperitoneal abscess; percutaneous

50021  Drainage of perirenal or renal abscess; percutaneous

58823  Drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous (eg, ovarian, pericolic)

New codes were created specifically to describe draining fluid collections by catheter, defined within the code descriptors as an abscess, hematoma, seroma, lymphocele, cyst, or other similar contained fluid collection.

New CPT® codes, effective Jan. 1, 2014:

10030  Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous

49405  Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous

49406         peritoneal or retroperitoneal, percutaneous

49407         peritoneal or retroperitoneal, transvaginal or transrectal

Note: Code 49407 requires the needle or catheter to be passed through the vagina or rectum to reach the fluid collection within the rectum. This code is not reported for draining fluid from the vagina.

Percutaneous fluid drainage involves inserting a large bore needle or catheter into fluid collection to drain that fluid. The device is often left in place to allow continuous fluid drainage, as needed. Because the procedure is performed without an open approach, many physicians use imaging—including fluoroscopy, ultrasound, computed tomography (CT), or magnetic resonance imagery (MRI)—to guide the needle insertion and confirm the needle accesses the fluid. S&I of the imaging is always included.

Never report the following radiologic S&I CPT® codes with percutaneous image-guided fluid collection drainage codes:

75989  Radiologic guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation

76942  Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

77002  Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

77003  Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)

77012  Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation

77021  Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

Percutaneous image-guided fluid collection drainage codes may be reported once for each fluid collection drained, but may not be reported more than once per fluid collection, regardless of the number of times the fluid collection is accessed.

Clinical Scenario 1

Indications: A 67-year-old patient presents with fever and left, upper-quadrant pain increasing over the past 36 hours. The pain is not associated with eating a meal or other event. Patient has known cirrhosis secondary to alcoholism. CT indicates a right hepatic abscess.

Procedure: The physician identifies the right hepatic lobe abscess using imaging guidance. The abscess is accessed using a guidewire. The physician aspirates purulent material, which is sent for culture. The access point is dilated to allow placement of a drainage catheter, which is sutured in place without complication.

Coding: 49405

Clinical Scenario 2

Indications: A pediatric patient with a history of chronic throat infections presents with continued swelling and pain in the neck, not associated with a current infection. The physician suspects retropharyngeal abscess secondary to lymph node breakdown, versus cellulitis. CT confirms there is an abscess.

Procedure: Using CT imaging, the physician identifies the retropharyngeal abscess and enters the fluid collection with a guidewire. Purulent material is aspirated and sent for culture. The access point is dilated to allow placement of a drainage catheter, which is sutured in place without complication. The patient is kept inpatient until the drain can be removed.

Coding: 10030

New Codes Apply to Percutaneous Drainage, Only

The new codes only apply to percutaneous drainage by catheter and certain transvaginal and transrectal drainages. Many new parenthetical instructions have been added to CPT® to redirect you to other drainage codes. In all, CPT® added or revised 30 parenthetical notes regarding correct coding for fluid drainage. For example, following 49407, parenthetical notes direct the coder to thoracentesis, percutaneous pleural drainage, open drainage, and peritoneal drainage codes.

CPT® retains existing codes to report specific percutaneous procedures. For example, percutaneous cholecystostomy (creating a surgical opening in the gallbladder using a percutaneous approach) is still reported using 47490 Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation; and cavity drainage is still reported with codes for thoracentesis (32554 Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance, 32555 Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance) and abdominal paracentesis (49082 Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance, 49083 Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance).


Terri Brame, MBA, CHC, CPC, CPC-H, CPC-I, CGSC, is the compliance education officer for the University of Arkansas for Medical Sciences. She is also the author of E&M Coding Clear & Simple, Evaluation & Management Coding Worktext, published by F.A. Davis, the Taber’s Cyclopedic Medical Dictionary publisher. Brame is a member of the Little Rock Central, Ark., local chapter, and a past local chapter president.

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Have a Realistic Approach to Developing ICD-10-CM Superbills

The process is fairly simple, but it requires time, analysis, and research.

By Susan Theuns, PA-C, CPC, CHC

ICD-10 implementation is approaching, and many practices are relying on vendors to make sure all of the pieces are in place to “go live.” But what if they aren’t ready? For practices using manual superbills/encounter forms, a contingency plan will ensure an uninterrupted revenue stream for Part B services billing beyond ICD-10 implementation.

Create a Timeline

Updating a superbill can be a time-consuming process, and you must anticipate time for printing (especially if you use an “outside” vendor) and distributing forms. The following timeline is recommended for internal superbill conversion from ICD-9-CM to ICD-10-CM:

  • Early 2014: Review existing form(s) and begin process (see “Step Out the Process” section) using 2014 ICD-10-CM codes.
  • June 2014: Send updated form(s) with ICD-10-CM codes to your print vendor for proof set up.
  • August 2014: When 2015 ICD-10-CM codes are released, review and update the superbill proof. Return the final, updated form(s) to the print vendor for final proof.
  • September 2014: Submit a print order to vendor, with a delivery date to sites prior to the Oct. 1 effective date.

Hire a Print Vendor

Selecting a reliable print vendor is critical when updating your superbill. Look for a vendor with a reputation for putting out a good product, with reasonable prices, and a quick turnaround. To ensure your forms are printed and ready for use in offices by Oct. 1, agree on a timeline with your vendor. When the timeline is finalized, the process to create the superbill can begin. Maintain close communication with the print vendor to ensure everything stays on course.

Step Out the Process

The steps below will yield a single two-sided superbill, with header and services on the front and diagnosis codes on the back. The front of the form should already be set with current codes from the January 2014 updates.

Here is a basic process for updating a single-specialty form:

  1. Review existing ICD-9-CM codes on your current forms. Compare it with a “top 100 most used diagnoses” report, using frequency reports from the appropriate billing system(s).
  2. Revise the list of ICD-9-CM codes based on report data and changes in practice.
  3. Select the top 20-50 diagnosis codes (as space allows, for a single page).
  4. Refer to the Centers for Medicare & Medicaid Services’ (CMS) general equivalence mappings (GEMs) to compile a new list of codes using ICD-10-CM. Note that GEMs are not 100 percent accurate, so it’s best to code directly from the ICD-10-CM code book, when possible.
    1. For each specialty, include applicable manifestation codes for the most commonly used diagnostic conditions in the category.
    2. For the top 20 most-used codes (based on the frequency report), include all codes to the most specific character (i.e., if the code requires six characters, the reported code must include all six characters, or it will be invalid for billing purposes).
    3. In each category listed, include blank lines for the provider to include more specific information or additional codes and information not listed on the superbill.
    4. Furnish additional codes that cannot fit onto the form (on a single side) using laminated reference guides (either produced in-house or purchased).

Be Realistic

No one expects every possible code to fit on a standard superbill. But with some planning and knowledge of the most commonly diagnosed problems by specialty and provider, you certainly can cover the codes that are used most frequently. Knowing your clinicians and patient population is key.

For example, there are many different types of diabetes that can be coded in ICD-10-CM, but the two most commonly diagnosed types are type 1 and type 2. Do not try to fit every possibility on the form. Clinicians can write in diagnoses outside of the norm for look-up or use a reference guide to assign a code.

As you transition to ICD-10-CM, the goal should be to code to the highest level of specificity without getting bogged down with details that will not affect care or billing. Finding this balance may take time.

The process of developing a superbill is fairly simple, but it requires time and a lot of analysis and research. Having a backup plan for tentative vendor failure, however, will add peace of mind, as well as familiarize staff and providers with the new codes and nomenclature. Recognition and familiarity may help to alleviate the “fear factor” of the upcoming transition.

Healthcare business professionals, including compliance professionals, coders, billers, auditors, and clinicians, need to be ready to meet the requirements of ICD-10-CM because they are directly tied to reimbursement. It’s up to coding and compliance professionals to lead the way, to implement the tools for billing, to provide training for a smooth and successful transition to ICD-10-CM, and to provide reassurance that it can be done!


Susan Theuns, PA-C, CPC, CHC, is administrative director of physicians’ practices at MedStar Union Memorial Hospital and has an extensive background in healthcare, business management, facilities/operations, and compliance, spanning more than three decades. She holds a master’s degree in leadership and education and a Bachelor of Arts degree in business management. Theuns is a certified physician assistant, coder, and healthcare compliance professional. She serves on the advisory board for OptumInsight and is a contributing author for The Business of Medical Practice. She is a member of the Baltimore, Md., local chapter.

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