Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC, is RCM Compliance Manager, Experity
With the fall season comes all the coding changes for the year. This starts with the 2024 edition of the ICD-10-CM codes, which went into effect on October 1, 2023. As a reminder, there is no grace period. Changes are effective on dates of service as of October 1. Prior to this date, practices should continue to use the 2023 ICD-10-CM code set.
This year, there are 446 changes: 396 new codes, 25 deleted codes, and 13 revisions.
Revisions are important because they involve a change in description versus a change in code number. However, this year, the changes are mainly grammatical and have minimal impact in the urgent care setting.
Deletions usually involve the addition of digits to an existing code to be even more specific. For example, supraventricular tachycardia, code I47.1, now requires a fifth digit:
- I47.10 – Supraventricular tachycardia, unspecified
- I47.11 – Inappropriate sinus tachycardia, so stated
- I47.19 – Other supraventricular tachycardia
A fifth digit was also added to pneumonia due to other Gram-negative bacteria and to acute appendicitis:
- J15.61 – Pneumonia due to Acinetobacter baumannii
- J15.69 – Pneumonia due to other Gram-negative bacteria
- K35.200 – Acute appendicitis with generalized peritonitis, without perforation or abscess
- K35.201 – Acute appendicitis with generalized peritonitis, with perforation, without abscess
- K35.209 – Acute appendicitis with generalized peritonitis, without abscess, unspecified as to perforation
- K35.210 – Acute appendicitis with generalized peritonitis, without perforation, with abscess
- K35.211 – Acute appendicitis with generalized peritonitis, with perforation and abscess
- K35.219 – Acute appendicitis with generalized peritonitis, with abscess, unspecified as to perforation
Parkinson’s disease will require a fourth and fifth digit to identify if the patient has dyskinesia with or without fluctuations:
- G20.A1 – Parkinson’s disease without dyskinesia, without mention of fluctuations
- G20.A2 – Parkinson’s disease without dyskinesia, with fluctuations
- G20.B1 – Parkinson’s disease with dyskinesia, without mention of fluctuations
- G20.B2 – Parkinson’s disease with dyskinesia, with fluctuations
- G20.C – Parkinsonism, unspecified
Codes for a caregiver’s non-compliance with a treatment plan added digits to indicate if the reason is due to financial hardship. This would be considered a social determinant of health and may have an impact on the management risk for leveling an evaluation and management visit.
- Z91.A41 – Caregiver’s other noncompliance with patient’s medication regimen due to financial hardship
- Z91.A48 – Caregiver’s other noncompliance with patient’s medication regimen for other reason
- Z91.A51 – Caregiver’s noncompliance with patient’s renal dialysis due to financial hardship
- Z91.A58 – Caregiver’s noncompliance with patient’s renal dialysis for other reason
- Z91.A91 – Caregiver’s noncompliance with patient’s other medical treatment and regimen due to financial hardship
- Z91.A98 – Caregiver’s noncompliance with patient’s other medical treatment and regimen for other reason
In new codes, there are several additions for foreign body sensation: H57.8A1 to H57.8A9 for the eye, R09.A0 to R09.A9 for the throat, nose, and all other sites.
Two codes were added to the list for chronic obstructive pulmonary disease:
- J44.81 – Bronchiolitis obliterans and bronchiolitis obliterans syndrome
- J44.89 – Other specified chronic obstruction pulmonary disease
An option was added for hypertension: I1A.0, resistant hypertension.
The complete list of changes can be found on the Centers for Medicare and Medicaid Services’ website.
COVID-19 Guideline Changes
Instructions for coding for COVID-19 have been updated. Previously the guidelines stated that a screening diagnosis is generally not appropriate during a public health emergency. This language has been removed and replaced with: “For screening for COVID-19, including preoperative testing, assign code Z11.52, encounter for screening for COVID-19.” A screening is when a test is required, yet it is not medically necessary as the patient exhibits no signs of illness.
Asymptomatic individuals with actual or suspected exposure to COVID-19 should be reported with code Z20.822, contact with and (suspected) exposure to COVID-19. This test is not a screening as it is medically necessary. It is important that providers understand the distinction as insurance plans do not have to cover screenings, so this should be considered a cash pay service. Claims for exposure would generally be reimbursed by most insurance plans.
Also, avoid the use of the word “screening” if the reason for the visit does not meet the definition of a screening above. Use of the word “screening” while the patient has been exposed or is even symptomatic may result in a recoupment or denial on payer review.
If the patient is symptomatic and tests negative for COVID-19, be sure to report the symptoms to support medical necessity for the visit.
Common Diagnosis Coding Denials
Laterality: Laterality specifies whether the condition occurs on the right, the left, or is bilateral. A common coding error is to select the unspecified code. An example is ICD-10 H60.339 (swimmer’s ear, unspecified ear). These unspecified diagnosis codes appear to be a target for payer reviews.
Unspecified codes are necessary in some cases. They are used when insufficient clinical information is known for the provider to assign a more specific code. However, in the case of laterality, it means the provider has not identified or documented if the site being treated was on the right, left, or is bilateral.
In some cases, there is no bilateral option. The provider should list the ICD-10 twice: one code for the right and one code for the left.
Many of the Blue Cross insurance products adopted a new policy effective August 1, 2023, whereby they will deny claims that do not specify laterality.
Signs and Symptoms: Generally, if there is a definitive diagnosis, the patient’s symptoms do not have to be reported on the claim. This is correct coding according to the guidelines. However, the exception to this rule is diagnostic testing, especially laboratory testing. For these services, most payers require the symptoms for payment. This is done to ensure the test was medically necessary, regardless of the results.