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Changes in Medical Documentation with ICD-10 Coding

February 14, 2013

ICD-10-CM There’s never a quiet moment in today’s constantly changing regulatory atmosphere where healthcare reimbursement is concerned.  Keeping track of current changes in outpatient ICD-9 and CPT billing is difficult enough.  When you think about changes that are right around the corner with ICD-10 billing, it’s no wonder successful medical practices rely on professionals dedicated to submitting clean healthcare claims every time.

Recently, one of our documentation and coding specialists received a call from a client. She was in the midst of reviewing charts to prepare for a RAC Audit for another client. No worries. The practice being audited has partnered with M-Scribe within the RAC’s window.

“How can I help you?” our specialist asked.

“My doctor has questions about how to document melanoma under ICD-10-CM,” said the concerned medical assistant. Do you think you have time to talk to her?” We always have time to talk about ICD-10 documentation, coding, and billing.

In ICD-9-CM, malignant skin neoplasms fall under code sets 172 and 173. ICD-9-CM reserves the 172 subset for Malignant melanoma of the skin. In order to report a melanoma diagnosis to its greatest degree of specificity, an additional digit is required to indicate the location of the melanoma.  Some possible melanoma locations are not included in the 172 subset. Coders are referred to other codes outside those dedicated to skin melanomas.

ICD-10-CM is more thorough and comprehensive in pinpointing the location and pathology of diagnoses documented in the medical record. An auditor reviewing ICD-10 codes has no question of what medical condition a physician is treating in any given medical encounter. The same cannot be said about ICD-9-CM.

ICD-10 is being implemented to reduce confusion in coding and to increase the accuracy of healthcare claims while providing accurate reimbursement for medically necessary services. The detail contained in ICD-10-CM codes must be supported by a patient encounter’s documentation. When that documentation is in place, assigning ICD-10 codes will be simpler and when done correctly, increase cash flow.

The dermatologist got on the phone. “I’ve diagnosed an anal melanoma and I don’t know how to code it,” she said. This is a real medical condition that dermatologists encounter. Nobody likes to talk about it, including ICD-9-CM, which makes coding this condition confusing.

Under ICD-9, 172.5 describes Malignant melanoma of skin of trunk, except scrotum. Cross-referencing, which any good coder will do, shows this code excludes 154.3, Malignant neoplasm of anus, unspecified site. A review of ICD-9-CM’s text shows that melanoma can be coded as 154.3. Melanoma is not necessarily pertinent data when assigning an ICD-9 code, only malignancy. In the case of anal melanoma, ICD-10 provides more explicit direction.

In ICD-10-CM, C43.51 denotes Malignant melanoma of anal skin. This includes: Melanoma (malignant), anus, anal (skin), Melanoma (malignant), perianal skin, and Melanaoma (malignant), perineum.

In ICD-10, if the skin is involved, there is no question about how to assign a code for anal melanoma. The ICD-10-CM describes the exact pathology of the neoplasm as well as the site.

“Will this change what I enter into the patient’s medical record?” the dermatologist asked.

Accurate documentation is vital to a professional medical practice, and is key to good billing practices. If a diagnosis is documented as the physician would like to read it or written by someone else, it should be accurate enough to translate into ICD-10 codes.

There will be challenges ahead when ICD-10 becomes the coding standard in 2014.  M-Scribe Technologies is ready to meet them.


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