Tips for testing ICD-10 in 2013

March 10, 2013

This month we're focusing on ways to test ICD-10 in 2013.

This year brings two crucial International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10)-related transition milestones for providers, according to the Centers for Medicare and Medicaid Services (CMS):

  • April 1, 2013, is the day to start testing ICD-10 codes and systems with your practice’s coding, billing, and clinical staff. Use the ICD-10 codes for diagnoses your practice sees most often, and test data and reports for accuracy.

  • October 1, 2013, is the day to begin testing transactions from start to finish using ICD-10 codes with payers and other business partners.

It’s not too late to review your ICD-10 timeline to ensure that you are prepared. CMS recommends that you:

  • Review ICD-10 resources from the CMS, trade associations, payers, and vendors.

  • Inform your staff and colleagues of the upcoming changes.

  • Create an ICD-10 project management team.

  • Identify how ICD-10 will affect your practice.

Develop and complete an ICD-10 project plan for your practice by identifying each task, including the deadline and who is responsible for completion, and developing a plan for communicating with staff and business partners about ICD-10.

  • Estimate and secure budget (potential costs include updates to practice management systems, new coding guides and superbills, and staff training).

  • Ask payers and vendors of software/systems, clearinghouses, and billing services about their ICD-10 readiness; review contracts and proposals. Ask about system changes, timelines, costs, and testing plans, including how you and other clients will be involved.

Additional steps include reviewing your current ICD-9 diagnostic statements, ensuring that your documentation will support today’s diagnostic statements, and reviewing how the documentation will look in ICD-10 on October 1, 2014.

Claim rejections with modifier 25

Q: We billed Medicare for a physical and pneumonia vaccine with modifier 25. Medicare paid only for the vaccine and its administration, rejecting the physical. We also billed a physical with an office visit; during the physical, the patient had a problem with her eye and also sought to renew medications. Again, Medicare rejected the physical, stating that modifier 25 is not the correct one to use. Which modifier should we use?

A: Modifier 25 is not needed when a preventive medicine code is billed with a vaccine on a Medicare claim, as it was in your first example. V70.0 (routine general medical examination at a healthcare facility) should be linked to the preventive medicine code (99381–99397), and V04.81 (need for prophylactic vaccination and inoculation against influenza) should be linked to the vaccine and administration codes. Use code G0008 (administration of influenza virus vaccine) for Medicare beneficiaries.

In your second example, double-check to ensure that you’ve appended modifier 25 to the correct code. Modifier 25 should only be appended to an E/M code, not the preventive medicine code (99381–99429). If you submit the claim in this manner, then modifier 25 is the correct one to use.

Link your diagnosis codes to the correct Current Procedural Terminology codes on the claim to support medical necessity (for instance, the diagnosis code for the patient’s eye problem should be linked to the E/M-problem oriented-code, not the preventive medicine code).

If this patient was new to your practice, then a new-patient preventive medicine code and an established-patient E/M code need to be billed, because two new-patient codes cannot be billed on the same claim.

If you billed the claims appropriately, appeal the decisions.

The author is a billing and coding consultant for VEI Consulting Services, Indianapolis, Indiana. Do you have a primary care-related coding question? Send it to medec@advanstar.com. Also engage at www.twitter.com/MedEconomics and www.facebook.com/MedicalEconomics.