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HCFA changes rules for outpatient ICD-9 coding

From the January 1996 ACP Observer, copyright © 1996 by the American College of Physicians.

By Sharon Mikolanis

Beginning April 1, 1996, physicians will be required to document Medicare Part B services using ICD-9 codes that include the fourth and fifth digits, when they exist.

On March 4, 1994, HCFA issued a regulation in the Federal Register stating that the 1500 claim form must have ICD-9 codes included along with CPT codes for outpatient services and any other physician services billed to Medicare. The regulation explained that the highest level of specificity should be provided when using ICD-9 codes to provide more accurate, detailed health information data about a patient's condition. The fourth and fifth digits often describe anatomical sites involved in disease processes, the type of disease or syndrome or the symptoms associated with various health conditions. Physicians who do not provide this level of detail using existing ICD-9 codes may have their claims rejected by carriers as of April 1996.

Currently, some outpatient services may only be billed using ICD-9 codes carried to the third digit because this is the highest level of specificity available in the current 1995 ICD-9 coding system--for example, acute tonsillitis, 463; chronic renal failure, 585; and HIV disease, 042. However, some commonly treated diseases and syndromes may contain the fourth and fifth ICD-9 digits using the current list of existing codes.

Diabetes is one of the most frequently miscoded diseases. Here is how you would code the following presenting problems. A 70-year-old patient diagnosed with uncontrolled type 2 (non-insulin-dependent) diabetes mellitus with ketoacidosis would require code 250.12. A 10-year-old, controlled type 1 (insulin-dependent) diabetic person with no complications would require code 250.01. In these examples, the first three digits, 250, represent the disease entity--diabetes mellitus. The fourth digit denotes the manifestation of a disease complication and may range in value from 0 to 9. The fifth digit describes the type of diabetes and the level of control exhibited in maintaining normal blood glucose levels. For example, a "0" as the fifth digit means type 2 or unspecified and not stated as uncontrolled; a "1" means type 1 that is not stated as uncontrolled; a "2" means type 2 or unspecified type that is uncontrolled; and a "3" means type 1 and uncontrolled.

In the case of hypertensive disease, malignant essential hypertension is coded as 401.0 and benign essential hypertension is coded as 401.1. There is no fifth digit available for essential hypertension in the current coding system. You should not add or substitute numbers where they do not already exist in the coding scheme. For example, benign hypertensive heart disease without congestive heart failure is coded as 402.10, and benign hypertensive heart disease with congestive heart failure is coded as 402.11. To provide the specificity requested by HCFA, use digits already available in the existing coding system. When coding, do not add zeroes to codes to give them fourth or fifth digits when they do not exist in ICD-9. The code selected should accurately describe a patientÕs illness or disease and be listed in the latest ICD-9 edition.

There are several ways to improve your knowledge of and accuracy in ICD-9 coding. ICD-9 books are published in three volumes. The first and second volumes, usually published as one book, contain a disease-specific index and a numerical listing of ICD-9 codes, respectively. These two volumes are recommended to help physicians properly bill for outpatient services. The third volume contains procedure codes for hospitals only--so typically physicians do not need to purchase this volume. ICD-9 books are updated annually and new books should be purchased every year. Using the latest edition of the books is important to ensure that you and your office staff are up-to-date on coding changes made during the previous year. These books may be obtained from Medicode (800-999-4600), Channel Publishing (800-248-2882), and the American Medical Association (800-621-8335). Buy books that are plain and simple to read, and beware that books claiming to improve your reimbursement rate frequently do not help you to do so.

HCFA participated in preparing a file on CD-ROM containing all ICD-9 codes. The CD is available for $17 from the Government Printing Office. To order, call 202-512-1800 and use the order number 017-022-01316-9. This is a "read-only" file meaning that you cannot transfer information to or from it. The CDC also has a World Wide Web page available via computer network that contains volumes 1 and 2 of ICD-9-CM. You may download this file to your computer system and use it as a reference; however, make sure that your computer has adequate memory to store this large file.

Both you and your office staff can also improve your coding by attending local coding clinics. Health information management staff at a local hospital could provide an in-service for you, your colleagues and office staff. Or it may be worthwhile to have a consultant teach and advise you on how to accurately bill for your particular case mix of patients.

For coding resources and other help, phone the American Health Information Management Association (AHIMA) at 312-787-2672. To order publications from AHIMA, call 800-335-5535.

Sharon Mikolanis is Associate for Payment Policy in ACP's Washington, D.C., office.

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