Section: CME Category: Practice Management

Know the pitfalls of ICD-10 Coding: there are issues getting paid

David Freedman, DPM, APMA, CPC, CPMA, CSFAC

David J. Freedman, DPM, FASPS, CWS, CSFAC, CPMA instructs Don't be fooled! Just because you have been submitting diagnoses since 10/1/2015, ICD-10 issues have been developing that you should be aware of in your region and nationally. Dr Freedman will teach those that have popped up since ICD-10 went live and how to handle other coding issues regarding ICD-10.

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Goals and Objectives
  1. Understand The 7th character
  2. Assign correct coding for sesamoiditis
  3. Know tendinopathy diagnoses based on type
  4. Properly code tears, if you are certain?
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  • Author
  • David Freedman, DPM, APMA, CPC, CPMA, CSFAC

    CAC-MD Representative
    Certified Professional Coder
    Certified Professional Medical Auditor
    Certified Surgical Foot and Ankle Coder
    Fellow, American Society of Podiatric Surgeons
    Diplomate, American Board of Foot and Ankle Surgery, Certified in Foot Surgery

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    David Freedman has disclosed that he is an Officer/Director for

  • Lecture Transcript
  • The title of this presentation is know the pitfalls of ICD-10 coding, their issues with getting paid. I am your host today David J. Freedman DPM Fellow of American Society of Podiatric Surgeons, a certified professional coder, a certified surgical foot and ankle coder and certified professional medical auditor. I am the principal for, a single resource for your ICD-10 needs. I've been on the APMA coding committee and member since 2005. I am the team manager for ICD-10 which started at 2010 and I have over 20 years of coding experience.

    Our financial disclosures include that I am the director officer of The objectives for today are: After participating in this activity the viewer should be better able to understand the seventh character, assign correct coding for sesamoiditis. No tendinopathy diagnoses based on type and properly code tears if you are certain.

    Know the pitfalls of ICD-10 coding to make sure you're getting paid is a major issue and that's part of our today's outline. Number one are the payer-specific hotspots that have emerged since the go-live date of October 1, 2015. Number two are the nonspecific codes, are there any dangers associated with these codes. Number three using an ICD 10 conversion tool is necessary and they are all not created equally and why should be your resource by example.

    Understanding claims in EOBs post October 1st of 2015, most people don't always look at this but it is important to determine any errors that may be a problem with your claims processing. There are primarily two parts of the process that one should know when it comes to submitting electronic claims. Those are 837 and 277 codes on your remittances for submitting claims and receiving claims, you should know the difference. And 837 means that the processed claim is coming back from the payer. And 837A means they have been accepted versus 837R means they have been rejected.

    The 277 means the claim has been sent to the payer and the 277A means they have been accepted by the payer successfully versus a 277R mean the claims have been rejected by the clearinghouse. These are key things because the staff can go into claims that have been rejected by a payer immediately rather than waiting for an explanation of benefits arrived in the mail electronically one week, two weeks, three or four weeks later when you can adjudicate your claims and fix them early on. So with the change in ICD-10 it becomes very prudent that all doctors’ offices and billing staff be more cognizant of the various issues associated with sending claims and receiving payment for claims.

    Some payer-specific issues that have surfaced. One area that has surfaced is one with NGSMedicare, they are the MAC that actually has 11 states that are under their contract. They clearly had LCDs that were supposed to convert their diagnosis but they did not. The LCDs were not lacking diagnosis previously in the ICD-9 but now are in the new LCDs for ICD-10.

    NGS LCD example for at risk for care, recently denied, has been reported that CPT 11056 and CPT 11721 with using E11.40 which is type II diabetes with neuropathy. Is that a possibility how could that happen? Well it turns out they are editing software claims for routine foot care and debridement of nails are processed incorrectly since the transition to ICD-10.

    NGS is adding some of these diagnoses as payable for the services and are correcting edits which resulted in incorrect denials. NGS has related that additional diagnosis will be included in the LCD and were supposed to be published after 11/30/2015 date. It’s very critical that you go back to the website look at the LCD if you're in NGS to see whether they've updated the LCD and what diagnoses are added and are payable under this LCD.

    NGS has also identified, submitted claims were paid for some services which did not meet the coverage criteria and have been paid and allowed in error. They are going to go back in this situation and doing unmask claim adjustment to pay correctly so no provider action is required but they may be taking back funds they paid previously because they feel it should not have been paid for, so pay attention to those claims and see if you need to change diagnosis to more specific diagnosis that are allowed in their inclusive list on their LCD on their website.

    What should you know about Novitas? Well you should know that Novitas is one of the MAC carriers that has 13 jurisdictions that they cover. They are Medicare MAC and they have created edits that can be causing problems that you may have not been aware of. In Novitas they had an ICD-9 edit for 681.11 paronychia which was in edit -- being a routine diagnosis this meant they did not cover this diagnosis previously with an E&M code.

    So guess what they have been denying since October 1st. The corresponding ICD-10 code when it mapped to ICD-10 it did not mapped the paronychia because paronychia does not have its own code. It turns out it's a cellulitis code and because it does not truly have its own diagnosis code they did not realize this. But because of the mapping it created problems so what does it mean to you.

    So what does this mean regarding the paronychia mapping? Well when you bill an E&M visit in Novitas 99211, 99212, 99213, 99214 or 90215 they have been denying the codes for cellulitis of toes whether it's right toe or left toe for L03.031 or L03.032 or L03.039 for unspecified toe. And it's important that they were made aware of this. I did personally speak to the Novitas representative and they have recognized that this is an edit error because certainly cellulitis is not paronychia and the Medicare carrier is understanding that this was an error and they are planning to go back and reprocess claims with these diagnosis codes as being covered diagnosis.

    If you find that the same diagnosis codes are being denied in your area you should be contacting your CAC Representative because the CAC Representative is the person that can help you get this resolved in your local jurisdiction.

    Meridian Medicare it covers over 16 states and territories and there was an issue that came up with foot care as well. They were required to use the same LCD guidelines that were used before the ICD-10 transition but claims are being denied and what do you need to do what do you need to know? Well it’s LCD ID number L34243 that became effective on 10/1/2015. It involves CPT codes 11055, 11056 and 11057. The claim must have at least one of the following 10 diagnosis codes either in L03.311, 312, 313, 314, 315 or 316 these are cellulitis diagnosis codes or M79.671, 672, 674 and 675 for pain and at least one of the following diagnosis codes.

    A continuation of the problem with Meridian regarding CPT codes 11055, 11056 and 11057, in order for these claims to be paid as discussed on the previous slide you must have at least one of those 10 paired with one of the following that are listed below. And these include L84, L11.0, L85.0, L85.1, L85.2, L87.0, L87.2, Q81.9 or Q82.8 one of these codes must be paired with the previous options on the previous slide that showed that these two diagnoses together would allow for coverage in this Meridian policy.

    WPS Medicare covers six states, there have been rejections for CPT 11721 as not a covered service are occurring [phonetic] [0:09:00] as well. If you're in one of the six states check your EOBs for denials, review the LCDs effective since October 1, 2015 for coverage criteria.

    A Blue Cross, Blue Shield and Alpha, bunionette has been occurring with M20.10 the unspecified coding but am M20.11 and M20.12 the right and left Hallux valgus diagnosis coding. The reason this is occurring is that bunion unfortunately is mapped to Hallux valgus and I know that Hallux valgus are two distinct deformities yet they are assigning PR-96 codes to these which are noncovered charges and they are also assigning the and N130 reason code that says that a consult plan, benefit documents guidelines for information about restrictions for the service.

    What happens is when you call a customer service, the representative is going to tell you that bunions are a plan exclusion under the policy and your comment back to them is that bunions do not have a diagnosis in ICD-10 and that unfortunately the mapping was sent to Hallux valgus but Hallux valgus is a distinct and separate diagnosis and they have the mapping incorrect for the proper diagnosis of bunion versus Hallux valgus.

    It’s important to find out whether that reverses or not or speak to a carrier medical directors to see if they’ll help change the policy because otherwise this policy in effect means that any of the Hallux valgus diagnosis codes are not a covered diagnosis. Another ICD-10 hotspot or dangers to be worried about are some of the nonspecific codes and one of them is sesamoiditis that would be the number one on my list because you will not find the diagnosis, so what do you do?

    You can look in the index for diagnosis in ICD-10 which helps to drive to the tabular version, you always need to then go to the tabular version and then decide if that code is the most specific code that you are planning to use. An effective resource that I created was where it takes the mapping puts it into the tabular all in one place and ends up giving you the specific code, it's very important to get the specific tabular code and not an index code only.

    Sometimes the EHR software that we use all has also the ability to enter a diagnosis by terminology, synonyms or the diagnosis code. Well it turns out many of the companies that use the software that was provided by CDC and CMS they just dump all the diagnosis codes in and if there is mapping issues such as the one we just stated like was sesamoiditis it would send you to the wrong diagnosis. Initially sesamoiditis was mapped to acute osteomyelitis which was not the correct diagnosis so it’s very important to make sure that you're not using the wrong diagnosis especially with a diagnosis like sesamoiditis.

    So what are the possible opportunities to use for the sesamoiditis diagnosis. Well clearly we have different options and these are listed here we've other disorders of continuity of bone whether it’s right ankle and foot and when you see the word ‘and’ in ICD-10 it could mean the word ‘or’ so it could be either or or both. So we have both a right and a left option there.

    we have skeletal fluorosis, again an M85.171, 172 option we've other specified disorders of bone density and structure M85.871, 872.

    We've other disorders of bone development and growth M89.271 and 272. We have hypertrophy of bone for M89.371 and 372 and there is osteolysis of the foot and ankle M89.571, 572.

    The ICD 10 hotspot with regard to sesamoiditis is that you have to go to the coding consensus in the community to see what would be the best fit for the diagnosis. And in this case with sesamoiditis it has been decided that M77.8 Other enthesopathies not elsewhere classified and that's what NEC stands for we you see not elsewhere classified would be the best option here because there is no specific diagnosis for sesamoiditis and the one that we would pick will be the one that sits best with the deformity that's present so M77.8 is considered currently the best option for sesamoiditis.

    Another ICD 10 hotspot or nonspecific code to be concerned about which is a danger is the nonspecific code for capsulitis when looking at the mapping from ICD-9-CM to ICD 10 CM one would provide an option in ICD-10 tabular but the problem is is that it's not specific. So let's look back at how this is decided. The suggestion that I have is start with the ICD-9-CM option of 726.90 which is capsulitis not otherwise specified. When you do the mapping to ICD-10 in the tabular section it does map to M77.9.

    This is enthesopathy unspecified. It has an inclusion term of capsulitis NOS which stands not otherwise specified so the option here says, let’s start with the capsulitis of a miscellaneous type code but is there a better option. When we look further into the tabular section we’ll see that there is the terminology for other enthesopathies of the foot and an enthesopathy can be a bone spur, it can be a bursitis, capsulitis and/or tendinitis. So we do have a more specific code that we can map to versus the unspecified code. And in here we have the other enthesopathy of the foot. On the right side would be M77.51 and for the left foot would be M77.52.

    ICD-10 hotspots for nonspecific codes: Are there any other dangers that we should know about. Well yes there's another one it’s called bunionette.

    When you look at the mapping from ICD-9 to ICD-10 it provides the option to go to ICD-10 tabular but the problem is we use 727.1 in ICD-9 that was for both bunion and Bunionette acquired.

    When you map this out it goes to Hallux valgus acquired unspecified or M20.10, clearly this is not an option for you because it's not a Hallux valgus. A bunionette is not a first metatarsophalangeal joint deformity, it's a fifth metatarsal deformity. So when we look at bunionette you have to go to the tabular section and look.

    The next thing you do to say what are the other options. We have M21.6X1 for other acquired deformities of the right foot. We have also the option for the left foot. These are other more specified but more broad used diagnoses that the patients can be applied for their specific diagnosis [Indecipherable] [0:15:58] this does not only mean bunionette, this is any other acquired deformities in the foot. The other alternative would be the M21.6X9 and that’s if you have an unspecified foot.

    So at this point in time I would like to show an example using the ICD-10 conversion tool created by In this clinical example it’s a straightforward example. You have been looking at some not so straightforward examples but now it’s time to look at a straightforward example.

    So a patient presents to your office there is a complaint that the back of the right Achilles tendon became painful after playing basketball last night. He iced it, wrapped it with an ace, elevated it and took ibuprofen 200 mg for them. In this example we're using Achilles tendinitis 726.71 using the resource tool. We are taking and putting the description of Achilles tendinitis into the search menu.

    You also have the option to change the radial dial to the code and you could also put in 726.71. Either way when you put the description or the code in you then highlight it in gray, click the search key and then it takes you automatically to the series of codes within the ICD10help search tool. It gives you the mapping of 726.71 and it will show you that M76.61 would be Achilles tendinitis for the right leg which is in this case that we just described.

    Also understand there is an inclusion term for Achilles bursitis so if someone has specifically Achilles bursitis then they would be using this diagnosis as well. There is not another diagnosis. On the other side if they have a bursitis due to use overuse or pressure in another place that would be M70.– coding and there is also the opportunity to also use enthesopathies of the ankle and foot M77.5– here as well.

    [Indecipherable] [0:17:56] to rule that means that they can also have these additional codes in addition to the M76.61 option.

    Can I use unspecified, this is asked over and over again. And it really is specific to the jurisdiction that you are in. For example the answer will be sometimes yes and sometimes no. In our example here Novitas I73.9 for unspecified peripheral vas disease, yes it's an option that you can use.

    But if you look at the NGS website for I73.9 for unspecified peripheral vas disease the option is a no. So just because it's available in one place or with one payer doesn't mean it's going to be available with every other payer and this is an unspecified peripheral vascular disease so you have to make sure that the code fits and matches to your diagnosis that you use in that day. There may be other options you can use and you should also look at the LCDs they provide on the website to provide you the specific codes that are covered so you don't code in the wrong direction.

    Why should I use joint arrangement as a diagnosis as a practitioner? Well it’s important to first define what internal derangement of the joint means. It means a general term describing a mechanical derangement of the joint structure.

    This is a term often used when the doctor doesn't quite know the exact diagnosis but can determine that something is functioning incorrect. So when using this type of diagnosis when we want to try to use this for, where you are looking at an x-ray you are not quite sure what the underlying etiology is or maybe you're ordering a CT scan or an MRI or some test and you want to at least put down a diagnosis knowing that something in the structure functionally [phonetic] [0:19:42] wrong with the joint but you do not know the exact diagnosis.

    Let's look at joint arrangement as an option. We have four options for right and left. They include ankle and foot. So we have other specific joint arrangements of the right ankle not elsewhere classifiable at M24.871 and 872 for the left ankle. We have other specific joint arrangements of the right foot not elsewhere classifiable at M24.874 and for the left at 875.

    Plantar fascial tear, there is no specific code and it's really not an M72.2 right. Well let’s talk about this M72.2 means that you are speaking about a plantar fasciitis or a plantar fascial fibromatosis it does not necessarily mean a tear. It’s important to understand what the definition of a sprain is.

    And a sprain is classified as a stretching or tearing of ligaments so we need to see if there's a specified rupture of a ligament in the foot and if the diagnosis exists. In ICD-10 you really have two choices for the foot.

    We can clearly go to M72.8 other fibroblastic disorders meaning that there is something happened within the fibroblast of this ligament that has caused this to tear. It may not be a trauma and on the other hand we have other options which are trauma codes. We have other sprain of right foot at S93.691A with S93.691D and S93.691S. The other sprain of left foot would be S93.692A, S93.692D and S93.692S. At this point let’s digress for one second and let’s discuss what the add on seventh character means for A D and S when someone hears the letter A it is often meant to me the initial encounter for an acute problem so if the patient has an acute problem with their foot the letter A will be applied to that scenario.

    The letter D comes into play when it’s subsequent as an encounter for this problem, it’s not the initial encounter it’s usually the subsequent encounter for normal healing. The S stands for sequela and sequela stands for complication that’s above and beyond the diagnosis that’s here. That means with something else is happening to that part that requires additional diagnoses beyond the typical diagnosis that’s presented to you.

    Tendinopathy, this includes information and micro tears in a tendon and some people want to know what is the best coding for Peroneus Brevis, Peroneus Longus, tibialis anterior and tibialis posterior.

    Well that falls under the strain of muscles and tendons of peroneal muscle group we have at the lower leg level right side so we have S86.311A, S86.311D and S86.311S.

    The strain of muscle and tendons of the peroneal muscle group on the lower leg left side we have S86.312A, S86.312D and S86.312S.

    We also have the unspecified option which I do not recommend using when you know the specified left or right side.

    What about tibialis posterior partial tear tendinopathies. Again these would fall under the strain of the muscle and we have tendon options as well posterior muscle group at the lower leg level with the right codes which will be S6.111A and S86.111D, S86.111S if it's the left side it’s S86.112A, S86.112D, S86.112S of course there's also the unspecified side but that only would be used if the doctor did not specify what is right or left, highly unlikely that you would use in unspecified diagnosis code.

    How about the tibialis anterior tendinopathy? So you have to go the anterior tibial muscles or the anterior muscle groups and of muscles and tendons at the lower leg level and we have the right side and the left sides or S86.211A, S86.211D, S86.211S for the right leg. We have S86.212A, S86.212D and S86.212S for the left side.

    Now again there's an unspecified option but again we do not recommend using unspecified diagnosis when you have a right or left option to choose from.

    Sesamoid fracture of the foot has a nonspecific coding for that. There are no specific options under the ICD-10 coding so if they go to a more broader type of coding but as we know there are two typical sesamoid bones that we typically will see whether it’s the tibial or fibular sesamoid bones located under the first metatarsal.

    We certainly know there are other potential sesamoid bones in the foot and they're all coded using the same line of diagnosis codes. It’s also to be noted that when you see lower leg lower leg in ICD10 when there is no other options below that level includes not only the lower leg but would include ankle and foot.

    The other fracture of the right lower leg we have S82.891A for the initial episode of care.

    We have S82.891D for the subsequent encounter for routine fracture healing. We have S82.891G. This is the subsequent encounter for fracture with delayed healing. We have S82.891K.

    This is the subsequent encounter for fracture with non-union. We have S82.891P. P means that the subsequent encounter for fracture with malunion and we have S82.891S and this is for a sequela associated with the fracture.

    In addition we have the other fracture of the left lower leg for S82.892A,we have the S82.892D, S82.892G, S82.892K, S82.892P and S82.892S. There is a well option for other fracture of unspecified lower leg but certainly if the person appropriately documents will know whether it's right or left so the odds of using an unspecified diagnosis code are slim to none.

    This concludes the presentation today if you have any questions please contact me at DJ, thank you and good luck in your coding.