Q  Will changes or updates be made to ICD-10 coding and, if so, when?

Yes. In March 2016, the Centers for Disease Control released proposed ICD-10 changes for October 1, 2016. The final changes were posted on the CDC website on August 22, 2016. The changes include 1,974 new codes, 311 deleted codes and 425 revised codes. In addition to code changes, some tabular instructions were revised to provide clarity.

Q  What type of changes can we expect when coding for glaucoma?

As expected, laterality was added to the open-angle glaucoma code, H40.11x _. The sixth digit now specifies which eye—replacing the placeholder “x.” The seventh digit remains the stage of glaucoma. For example: Prior to October 1, 2016, a patient with primary open angle-glaucoma, moderate stage, left eye, was coded as H40.11x2. After October 1, 2016, it will be coded as H40.1122. The “2” in the sixth place designates left eye.

Q  Will dry and wet age-related macular degeneration codes adopt laterality also?

A  Yes. When originally published, dry AMD—regardless of which eye had dry AMD—was coded as H35.31. Wet AMD was coded as H35.32. The update effective October 1, 2016 not only adds laterality but also staging. The eye will be indicated by the sixth digit in the ICD-10 code, and the stage of AMD will be the seventh digit.  

Q  How are the stage codes described for dry AMD?

A  There are five stages, including “unspecified,” listed for dry AMD. They are:

0 - stage unspecified
1 - early dry stage
2 - intermediate dry stage
3 - advanced atrophic, without subfoveal involvement, advanced dry stage
4 - advanced atrophic, with subfoveal involvement.

The seventh character, the stage, of the ICD-10 code for dry AMD will be coded 0 to 4.

For example: H35.3112 describes a patient with nonexudative AMD in the right eye, intermediate stage. The sixth digit “1” indicates the right eye, and the seventh digit “2” represents intermediate stage.

Q  Does the same approach apply to wet AMD?

Yes, but with some variation. The sixth digit will be for laterality but for wet AMD only four stages, including “unspecified,” exist. They are:

0 - stage unspecified
1 - with active choroidal neovascularization
2 - with inactive choroidal neovascularization with involuted or regressed neovascularization
3 - with inactive scar.

The seventh character, the stage, of the ICD-10 code for wet AMD will be coded 0 to 3.

For example: H35.3221 describes a patient with exudative AMD, with active CNV in the left eye. The sixth digit “2” indicates the left eye, and the seventh digit “1” indicates active CNV stage.

Q  Is there a definition of the various stages of AMD?

A  Yes. There are several classifications of AMD in various publications. The American Academy of Ophthalmology uses the Age Related Eye Disease Study to classify AMD. They published it in their Preferred Practice Patterns document on AMD.  

Were changes made to the diabetic combination codes?

A  Approximately 260 new diabetic combination codes become effective on October 1, 2016.  Some examples include:

Diabetic retinopathy codes have added laterality, changing them from six to seven digits. For example, E11.3293 (Type II DM, mild NPDR, no DME, bilateral).

There are new diabetic codes, including other retinal disease and resolved disease, including: E11.3531 (Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye); E11.3552 (Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye); and E10.37x3 (Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral).

Are there additional changes to the retinal disease section of ICD-10?

Yes. A seventh character further describing the patient’s disease was added to the retinal vascular occlusion codes. The sixth digit continues to indicate each eye. For example:

H34.81 Central retinal vein occlusion:
One of the following seventh characters is to be assigned to codes in subcategory H34.81 to designate the severity of the occlusion:

0 - with macular edema
1 - with retinal neovascularization
2 - stable

H34.83 Tributary (branch) retinal vein occlusion:
One of the following 7th characters is to be assigned to codes in subcategory H34.83 to designate the severity of the occlusion:

0 - with macular edema
1 - with retinal neovascularization
2 - stable

Q  What types of changes were made to the instructions to provide more clarity?

A  After the introduction of ICD-10, considerable confusion surrounded the instructions for applying “Excludes 1” and “Excludes 2.” Many complained that some conditions with an “Excludes 1” notation could also have a second condition, but the “Excludes 1” note did not permit using both codes. In the updated manual, some “Excludes 1” notes were changed to “Excludes 2” notes, allowing for conditions excluded by the “Excludes 1” note to now be coded together.  

For example, ICD-10 code H42 Glaucoma in diseases classified elsewhere previously contained an “Excludes 1” notation of diabetes mellitus (E08.39, E09.39, E10.39, E11.39, E13.39). This indicated that you could code one or the other, but not both. The update deletes the “Excludes 1” and adds Excludes 2: glaucoma (in) diabetes mellitus (E08.39, E09.39, E10.39, E11.39, E13.39).

Q  Will we continue to see coding leniency from CMS as long as we are in the right “family” of codes?

Very unlikely. CMS stated in July 2015 that it would not deny or audit claims just for specificity for one year after implementation of ICD-10, as long as the ICD-10 code was from the appropriate “family of codes.” Most Medicare contractors accepted and paid claims with unspecified codes as long as the code was from the appropriate family of codes. However, the “honeymoon period” ends as of October 1, 2016.  

Q  What other possible issues are of concern for us with the implementation of these ICD-10 changes?

A  There are several things to monitor:

• updating your EHR and practice management system;  
• training regarding the new codes;
• monitoring coverage guidelines and Local Coverage Determinations by payers; and
• being prepared to contact payers if new codes are not added to coverage policies.  REVIEW

Ms. McCune is vice pres­ident of the Cor­coran Con­sult­ing Group. Con­tact her at DMcCune@corcoranccg.com.