ICD-9-CM Coding Changes Impact Wound Care Practices

Advances in Skin & Wound Care, Sep 2004 by Schaum, Kathleen D

Q: Does Medicare require ICD-9-CM codes for wound care services rendered at sites other than a hospital?

A: The Health Insurance Portability Accountability Act (HIPAA) requires all paper and electronic claims to include appropriate ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes. This applies to physicians, nonphysician practitioners, independent clinical diagnostic laboratories, occupational and physical therapists, independent diagnostic testing facilities, audiologists, and ambulatory surgery centers.The only exception is for ambulance supplier claims.

The following is a brief history of The Center for Medicare and Medicaid Services' (CMS) ICD-9-CM coding requirements:

* 1979: ICD-9-CM codes become mandatory for reporting provider services on Form CMS-1450.

* 4/1/1989: ICD-9-CM codes become mandatory for reporting all physician services on Form CMS-1500.

* 10/1/2003: ICD-9-CM codes become mandatory for reporting all paper and electronic claims, except ambulance claims.

* 10/1/2004: CMS will no longer provide a 90-day grace period for physicians, nonphysicians, practitioners, and suppliers to use in billing discontinued ICD-9-CM diagnosis codes on Medicare claims. HIPAA requires that medical code sets-like the ICD-9-CM diagnosis codes-be date-of-service compliant.

Q: When are ICD-9-CM codes updated?

A: ICD-9-CM codes are published each year in the April or May Federal Register as part of the proposed changes to the Hospital Inpatient Prospective Payment System; they become effective each October 1. So beginning October 1, 2004, wound care physicians, nonphysicians, practitioners, and suppliers must use the current and valid diagnosis codes that go into effect that day. Specifically, these apply to service provided on or after October 1, 2004, and discharges on or after October 1, 2004 (for institutional providers).

Q: CMS states that claims should contain the ICD-9-CM code that provides the "highest degree of specificity." What does that mean?

A: CMS expects wound care providers to use the ICD-9-CM code that gives the highest degree of accuracy and completeness and that most fully explains the narrative description of the patient's symptom or diagnosis. Level of specificity refers to the 3, 4, or 5 digits of the ICD-9-CM codes. If a 3-digit code has 4-digit codes that further describe it, the 3-digit ICD-9-CM code is not acceptable for claim submission. Likewise, if a 4-digit code has 5-digit codes that further describe it, then the 4digit code is not acceptable for claim submission.

Q: If a wound care physician orders a diagnostic laboratory test, must an ICD-9-CM code accompany the order?

A: Yes, the physician or nonphysician practitioner ordering the service shall provide the diagnosis at the time the service is ordered. The laboratory or other diagnostic testing provider must include the diagnostic codc(s) furnished by the ordering physician or nonphysician practitioner on the Medicare claim. In the absence of an ICD-9-CM code, the laboratory or other provider may determine the appropriate ICD-9-CM code based on the ordering narrative diagnostic statement or seek diagnostic information from the ordering physician or nonphysician practitioner. However, a laboratory or other provider may not report a diagnosis code in the absence of the physician or nonphysician practitioner's diagnostic information supporting the code.

Q: Do any ICD-9-CM code changes pertain to wound care?

A: Yes, several new ICD-9-CM codes will affect wound care providers on October 1, 2004. Examples include the following:

* 707.00 Decubitus ulcer, unspecified site

* 707.01 Decubitus ulcer, elbow

* 707.02 Decubitus ulcer, upper back

* 707.03 Decubitus ulcer, lower back

* 707.04 Decubitus ulcer, hip

* 707.05 Decubitus ulcer, buttock

* 707.06 Decubitus ulcer, ankle

* 707.07 Decubitus ulcer, heel

* 707.09 Decubitus ulcer, other site.

Note that 707.0 Decubitus ulcer will be an invalid ICD-9-CM diagnosis code effective October 1, 2004. A fifth digit is now required to report the specific location of the wound.

See Table 1 for more examples of revised ICD-9-CM codes. These minor diabetes code changes have a major impact on coding for patients with diabetes who have wounds. Now, providers will focus on whether the patient has type 1 or type 2 diabetes, rather than on whether the patient is insulin-dependent or non-insulin-dcpendent.

Summary

In the past, Medicare has permitted a 90-day grace period after the annual October 1 implementation of an updated version of the ICD-9-CM codes.This grace period gave providers and suppliers time to become familiar with the new codes and to learn about the revised and discontinued codes. During the 90-day grace period, providers and suppliers could use either the previous or the new ICD-9-CM diagnosis codes. The HIPAA Transaction and Code Set Rule no longer permits CMS to continue with the 90-day grace. To maintain HIPAA compliance, providers and suppliers must begin adhering to the new, revised, and discontinued ICD-9-CM codes effective for dates of service on and after October 1, 2004. Claims containing discontinued ICD-9-CM codes will be returned as"unprocessable."