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Payments for some, pain for others with ICD-10


The ICD-10 road into November has been smooth for some physicians and bumpy for others in our latest ICD-10 Diary project entries.

Sue Osborne, DOSue Osborne, DOFamily medicineFloyd, Virginia

Where Are the Flaming Water Ski Injuries?

Oct. 30, 2015

We are doing OK so far. I think we have started to get paid using the new codes, so the major worry others told us to have is passing.

(The experts said to have six months of operating expenses in the bank. Right. Like we have even a week of operating expenses in the bank.) 

We clinicians code our own charts, and our EHR seems to be dredging some passable ICD-10 configurations, but the lab computer is having some problems. The lab company doesn't seem to have any kind of ICD-9 to ICD-10 conversion possible, and what used to be our best search program now is rendered nonsensical. It's a large national lab, so they may have some system problems. I had a number of ICD-9 codes memorized, and now one or two ICD-10 codes are starting to stick. (Z00.01: "My new health insurance only pays for physicals, so can we call this blood pressure check a physical?")

The more highly paid professions have more detailed codes and family practice? Well, it's October, and the choices for cold, flu, and bronchitis are somewhat limited and awkward. We're used to it. If they let me be in charge, there would be a code for "polypharmacy" (there is not), or, "My old doctor used to call in antibiotics when I had a cold so it won't turn into pneumonia." T75.82xA is there and I can't wait to use this code for weightlessness. Spontaneous combustion has, sadly, disappeared, perhaps due to new flame-retardant fabrics. "Sucked into a jet engine" [V97.33] used to be one of my favorites, but perhaps someone figured out there were too few survivors to dedicate the event a code.

Like Y2K, the end was predicted, and it did not seem to come. I felt most positive when I was told that we were simply catching up to rest of the world. Perhaps in other countries, injuries involving flaming water skis are more common.

NEXT: Putting 'Z' at the End



Katie Gilbert-Spear, OD, MPH, and Carl Spear, OD, MBA, FAAOCarl Spear, OD, MBA, FAAO, and
Katie Gilbert-Spear, OD, MPH Optometrists
Pensacola, Florida

Here's Z Issue

Oct. 30, 2015

We wondered how Z codes would affect our medical billing … and now we know. Z codes are a problem for us primarily in how the different insurance carriers are handling them.

Z codes designate the eye exam:

Z01.00 is eye exam without any abnormalities and Z01.01 are eye exams with abnormalities.

The guidance for using the Z codes is as follows:  

Z01.00 should be used for patients with eye exams on people with only refractive codes and no medical diagnosis. Z01.01 is to be used if patients are there for an eye exam and they have a medical diagnosis in addition to refractive disorders.

We were told Z codes should be on all claims as first diagnosis when filling 92004 and 92014 exam codes. If the Z code is Z01.01, any abnormalities or medical diagnoses should follow the Z01.01 code. The refractive codes should link to the refraction only.

Many of the payers (Blue Cross Blue Shield, Aetna, UHC, etc.) have denied claims as non-covered using the Z01.01 as primary diagnosis code. So we have learned that on all medical claims we put the medical diagnosis first and put the Z code at the end. This has delayed some of our medical claims payment and we have resubmitted the claims.

NEXT: Getting to Know You ….



Carla J. Lambert, MDCarla J. Lambert, MD
Family medicine
Beltsville, Maryland

Where Does the Time Go?

Oct. 30, 2015

Our transition has been relatively smooth with no known payment glitches yet.  ICD-10 does, however, slow things down a bit since I have to look up every code for every patient.  I have memorized exactly four ICD-10 codes as opposed to the many ICD-9 codes I can recall at a moment's notice.  I need to look up codes for referrals and authorizations which were previously submitted and approved.  We have also had to redo lab orders to change all the diagnosis codes.  ICD-10 is just more time-consuming, but hopefully this will decrease as time goes on. 

Due to the extra effort, my claims submission is a little delayed and I am not always able to finish submitting claims the day of the visit. (This will be a big problem in my small solo practice if this continues!)

I'm glad for the one-year delay on specificity, but I wonder how next year's transition will go.

Our EHR went down temporarily on Oct. 29.  I'm not sure if this was related to the ICD-10 updates.  I have actually been very pleased with my (free) EHR from Practice Fusion.  They have done a good job updating and making the ICD-10 transition a lot easier.  Again, the codes are not very specific at this point, but I imagine they will become more specific as the year goes on and we are required to increase the detail.


 NEXT: Meeting Those Year-End Bills



Pamela J. Miller, ODPamela J. Miller, OD
Highland, California

Diagnosis Disagreement

Oct. 27, 2015

I see absolutely no reason to include diagnosis codes for any systemic issues on most of the billing, since I don’t get paid for it. Most patients in my area are covered under Inland Empire Health Plan. Since the Affordable Care Act, this means the reimbursement is welfare rate-under $50 per patient-and minimal reimbursement for glasses, and only for children.

Oct. 28, 2015

Still not seeing reimbursements under ICD-10, but should be seeing something coming in with insurance this next week.

Oct. 29, 2015

It will be interesting to see how optometry is included in the medical model in this area. Thus far, it is almost non-existent. We don’t see many Medicare, Tricare, Blue Shield or patients on welfare, since most have to be referred down to the primary.

Optometry in this area is not in good shape and the California Optometric Association doesn’t seem to be able to change the system to include optometrists, despite the fact that they are considered physicians under Medicare.

Oct. 30, 2015

Nothing much has changed, except that it takes a bit longer to do the coding and my staff is doing pretty darned good trying to figure out the correct coding and making certain that I do my job.

Being a solo practitioner has a lot of positives, but there are a few downside things as well, and the paperwork (or computer work) is definitely right up there on the negative side. This time of year starts getting a bit more challenging due to the increased filings, taxes, bills, etc., that come due between now and year's end. So reimbursement on services will be critical in making the bills.

NEXT:  'No Major Glitches'



Thomas A. Marsland, MDThomas A. Marsland, MD
Orange Park, Florida

Sheepishly Optimistic

Oct. 30, 2015

Well it’s not March, but October came in like a lion and is going out like a lamb.

So far, we've had no problems.  Billing is OK. I received a memo from our carrier to be sure and report a denial due to a non-covered ICD-10 code that really should've been covered, and appeal that denial.

This week, I attended some meetings, including an American Society of Clinical Oncology meeting with payers and providers. Many of the though leaders in practice and medical directors from payers were there. I asked around and, really, there were no major glitches in ICD-10 so far. 

NEXT: New Coding System is a 10



Joseph E. Scherger, MD, MPHFamily medicine
La Quinta, California

More than 'Struck by an Orca'

Oct. 30, 2015

Employed physicians in larger groups and health systems with strong IT departments and software that prepared in advance for ICD-10 had little trouble with the transition.

The diagnostic language of ICD-10 is clear and consistent with the diagnostic language of medicine and much more complete than ICD-9. The obscure codes that people make fun of never come up in practice when you search for a code. 

NEXT: Coding Quandaries Persist



Mile Brujic, ODMile Brujic, OD
Bowling Green, Ohio

Medicare Miracle

Oct. 30, 2015

We have officially received our first Medicare payments in the era of ICD-10.

Things are going pretty smoothly, but 5% of our cases are taking up 90% of our coding discussion for ICD-10. Most of this discussion revolves around accidents and patients who have systemic conditions (e.g. Plaquenil patients) where specific tests and procedures are being performed.

NEXT: It's as Easy as ADS



Daniel Mark Siegel, MD, MSDaniel Mark Siegel MD, MS
DermatologistBrooklyn, New York

The ABCs of ICD-10

Oct. 30, 2015

It was an uneventful week leading up to Halloween.

One friend called asking about why all cancer codes start with C, while in situ, neoplasms start with D. As best as I can tell, this had to do with running out of numbers in the system as they got into the high C numbers. There's nothing evil I can find, but of course, you never know.

So far, I have not heard of payers not paying for in-situ malignancy treatment but with all the press about ductal breast carcinoma in situ not needing treatment, one never knows. The lines blur as The New York Times recently discussed.

Of course, maybe the confusion is the letter D itself. Not only is it the starting letter for in-situ carcinoma (D00-D09), benign neoplasms (D10-D36) and neoplasms of uncertain or unknown behavior (D37 - D48) and a host of blood diseases (D50-89), but it is also the seventh and final digit code extension; a.k.a. the seventh character for injuries and external causes where you were dumb enough to do it again.

A seventh digit "A" identifies if the encounter is initial, such as, “It was A bloody shame you fell into a hole (W17.2XXA) and got bitten by a turtle (W59.21XA)."

D as the seventh digit tells the reader it was a subsequent encounter, for example, “It was rather Dumb to get sucked into that jet engine again (V970XXD)!"

Sequelae are reported with a seventh digit of S. For example, if after being bitten by a turtle or and/or sucked into a jet engine, you then developed cellulitis as a result of the wound, you would report W59.21XS for the former and W59.21XS for the latter, along with the appropriate codes for the infection. Though I still have not figured out how you were put back together after your first pass through the jet engine, so you develop sequelae. Go figure.

NEXT: So Far, No Payments



Mohammad Rafieetary, OD, FAAOMohammad Rafieetary, OD, FAAO
Germantown, Tennessee

Payment Problems

Oct. 30, 2015

Being a single subspecialty (ophthalmology-retina) practice, the coding part has not been the challenge as much as the posting of the charges.

My business office manager tells me we still have not received any payments under ICD-10. That makes approximately 500 claims posted since Oct. 12 and we are still waiting …

NEXT: Floating Through ICD-10



Melanie Denton, MDMelanie Denton, MD
Charlotte, North Carolina

Things Still Looking Up

Oct. 30, 2015

We've made it through one whole month of ICD-10!

For me, aside from still searching for "vitreous floaters" as it was called in ICD-9 rather than "vitreous membranes and strands" as it is known in ICD-10, the transition has been relatively smooth. For the most part, I would say the ICD-10 codes are more descriptive and more accurate than their predecessors, and I think ultimately that will help us as physicians to quickly and accurately describe disease states for our patients. On the reimbursement end, I have not yet heard of any delays, and while my office probably bills more vision codes than medical, it's still a positive sign.


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