When discussing diagnoses (ICD-10-CM), there are important topics that need to be covered:

Each year the CDC distributes the latest diagnoses that providers must use for billing HIPAA covered entities. Follow this link to go to the web site to access the information. It’s important to know that the codes are released in July and then activated on the 1st of October each year. The problem with the delay in implementing ICD-10-CM is that there has been a code freeze for adding new codes. This means that any missing codes that were discovered going back to almost 2010 have not been added in the version that each of us started using on October 1, 2015 and you are now using the 2016 version. Next year’s version 2017 will become available in July and implemented on October 1, 2016.

Currently, you should be using the diagnoses that are published in the 2016 version. You may find some diagnoses that are more generic and void of specificity. When we received ICD-10-CM information, we were all told this diagnosis system will be more specific and include laterality. What we have learned is that there are some very specific diagnoses that we are now able to use, yet there are very nonspecific diagnoses that have a broader meaning. A common foot and ankle diagnosis is plantar fasciitis, M72.2. It has no laterality. It includes plantar fascial fibromatosis like it did in ICD-9-CM. What happens if the patient develops a plantar fascial tear? There is no better diagnosis code than M72.2 or one must consider M72.8 Other fibroblastic disorders. Alternatively, there are options under the classification of sprain. 1) Other sprain of right foot S93.691A; S93.691D; S93.691S or 2) Other sprain of left foot S93.692A; S93.692D; S93.692S

Don’t give away your ICD-9-CM version anytime soon. In case you did not know it, workers compensation and automobile insurance policies are not HIPAA covered entities. These insurers are not required to use ICD-10-CM. You need to make sure whether the company you are billing is using the new or old diagnosis system to get paid. Have your office verify which coding system the insurance accepts before submitting claims. One more exclusion was created by CMS. It allows small insurers (covered HIPAA entities) to file an exemption; they are not mandated to switch to ICD-10-CM. So, verify that the small insurance plan you plan to submit claims to will require ICD-10-CM.

Last, you need a resource to look up the coding you are using to make sure it is appropriate. I use my source to reference the mapping from ICD-9-CM to ICD-10-CM and use it for the ICD-10-CM tabular. It is important to not take what others say, but to validate through a resource that the information you are using is appropriate and accurate. Go to the payer web sites such as your Medicare MAC, BCBS, UHC, Aetna, CIGNA, etc and validate your diagnoses now. I strongly recommend that you don’t wait for denials. Payers said they would pay initially, but if you are using less than specific codes, it is very reasonable that although early on codes may be accepted that denials might start happening in the future. Pay attention to your EOBs. Ultimately, you are held to the highest standard and therefore the most specific diagnoses should be used.

Happy Coding!

David J. Freedman, DPM, CPC, CPMA

[email protected]