Outpatient radiology coding and radiology billing are about to undergo a change in how their services are reported on clean healthcare claims. When the national healthcare reimbursement system transitions from ICD-9 to ICD-10, greater specificity will be required in diagnosis coding.  The codes used after the transition will more accurately reflect the contents of the medical record, but it will require increased professional competence from medical billers who specialize in radiology services.  

The layout and structure of ICD-9 coding methodology are mirrored in ICD-10.  The new system, however, greatly expands the number of options that coders will have when assigning codes to describe medically necessary services.  The current ICD-9 system includes 17,000 codes to describe medical conditions, external causes of morbidity, factors influencing health status, and inpatient medical procedures.  ICD-10-CM contains 68,000 codes, not including the codes in ICD-10-PCS which describe procedures. This expansion in the availability of possible codes will require attentive review of available documentation in order to submit clean claims for timely reimbursement.

At first glance, the amount of detail contained in an ICD-10-CM code for an closed Bennett’s fracture may seem daunting when compared to its ICD-9-CM counterpart.  A patient diagnosed with a right-sided closed Bennet’s fracture is assigned the code 815.01, Closed fracture of base of thumb (first) metacarpal.  Using ICD-10-CM, the appropriate code will be S62.211A, Bennett’s fracture, right hand, initial encounter for closed fracture.  A closed Bennett’s fracture of the left hand is coded S62.212A for its initial radiological examination.

A follow-up visit ends with a different letter.  A patient referred for an x-ray of a healing Bennet’s fracture on the left is assigned the code S62.212C for a subsequent encounter for fracture with routine healing.  It could also be coded S62.212D for a subsequent encounter for fracture with delayed healing.  It could be coded S62.212K for a subsequent encounter for fracture with nonunion, or S62.212S for sequela following a historic closed Bennett’s fracture of the left hand.  

The medical record should have the radiological diagnosis amply documented to substantiate code assignment under ICD-10.

While translating the contents of the medical record, in this case the radiology report and requisition, into medical code is straightforward, the increased specificity of ICD-10-CM requires additional attention to detail when assigning codes.  Like ICD-9, ICD-10 can be considered a language separate from, but related to the medical terminology used in patient care.  Spelling is everything.

Using the incorrect sixth digit in an ICD-10-CM code provides different information, as does the transposition of the fifth digit of 1 for 2 in the case of laterality.  The specificity of ICD-10 coding allows third-party payers to more accurately track their beneficiaries’ ongoing treatment.  Payment can conceivably be denied for a subsequent encounter to examine a patient’s left-sided Bennett’s fracture if there is no record of an initial encounter, or if the patient’s claim history indicates that the initial fracture occurred on the right versus the left reported. 

By adopting ICD-10-CM as the standard for reporting diagnoses for reimbursement, the intent is to reduce incidence of healthcare fraud and abuse.  By specifically justifying medical necessity with highly detailed codes, a patient’s medical condition is more accurately described and monitored.

This information should be readily available in the patient’s medical record.  A radiology report should naturally contain the required information needed to properly assign ICD-10 codes.  Whether the fracture is a Bennett’s fracture or a Rolando’s fracture is apparent to anyone who reads a radiologist’s professional diagnosis.  So is which metatarsal presents the injury.  Likewise, whether this is a new fracture or an older one.  Any diagnosis that does not mention routine healing, delayed healing, or nonunion, will not be of clinical use to the physician who ordered the radiological exam.  The components of ICD-10-CM codes are already in the radiology record.  It takes trained, professional medical billers to review the record and assign codes appropriately for maximum reimbursement without denials or the need for appeals.  This is true under ICD-9, and it will be even more important under ICD-10.