Some hot ICD-10 codes for winter

Yes, winter is here. And with it comes some season-specific injuries. RT Welter identifies one very plausible use of ICD-10-CM coding:

  • S32.2XXA: Fracture of coccyx
  • W00.0XXA: Fall due to slipping on ice
  • Y93.H1XA: Shoveling snow
  • Y92.014: Place of occurrence, driveway

Even if a prolific plow industry suppresses the number of snow-shoveling injuries, there are many possible ICD-10 diagnoses that could be used this season.

Most winter activities that don’t involve a snow show shovel can be found in the Y93.2 neighborhood. For example:

  • Y93.23: Snow (alpine) (downhill) skiing, snow boarding, sledding, tobogganing, and snowtubing
  • Y93.24: Cross country skiing

And X37.2 may be needed to document the presence of a blizzard (either snow or ice).  if it’s extremely cold, warm up these two diagnoses:

  • T68: Hypothermia
  • X31: Exposure to excessive cold of natural origin

Even if patients manage to keep warm and safe inside, they still could suffer from a few more diagnoses:

  • F34.8: Seasonal Affective Disorder
  • R45.1: Cabin fever
  • E55.9: Vitamin D deficiency
  • X16.XXXA: Burned by electric blanket


This is a weekly feature that I use to highlight practical tips on how to use and understand ICD-10-CM/PCS codes. Please let me know of any other sources that I can include.

Five ways to use results from a coding audit

Coding audits are designed to find mistakes. There is a great incentive for healthcare providers to conduct their own audits instead of waiting for regulators or healthcare payers to find mistakes for them. Those kinds of audits could result in financial penalties.

The goal of coding audits should be to identify problems and create action plans to fix those problems. The result should be a more secure revenue stream.


Debi Primeau, president of Primeau Consulting Group, writes about a coding audit that found an overall accuracy rate of 96 percent. While congratulations were deserved all around, that didn’t mean there weren’t some takeaways.

  • Coding audits are valuable mechanisms to identify common denial areas.
  • Coding complications should be caught before a patient is discharged.
  • Use audit results to target education toward specific medical coders.
  • Computer assisted coding (CAC) and other technological aids should be considered to keep accuracy and productivity high.
  • Keep auditing.

Coding audits are opportunities for more than identifying mistakes. They can help improve processes and boost the expertise of the coding staff.

Medical practices need to brace for coding challenges

Healthcare is a constantly evolving industry. Medical knowledge thankfully increases constantly. But the regulatory and financial structures offer less welcome evolution.

Nancy Gagliano, MD,  and Randy Jones, DHA, look at some of the more important healthcare challenges in 2017 and try to frame them as opportunities:

  • Documenting accurately: Allow software to help capture clinical details instead of relying on copy and paste shortcuts.
  • Growing denial rates: Healthcare payers have more than a year of ICD-10 data and may change medical necessity standards.
  • Preparing for change: Medical practices need to understand the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Merit-based Incentive Payment System (MIPS), and how to prepare for them.

These transitions require teamwork and training to keep medical practices running and providing quality care to patients.

Reporting noncompliance is part of medical coder’s job

There is no question that medical coders need to adhere to compliance standards. Perhaps less understood is that coders are expected to report noncompliant activities at their employers, according to Rose Dunn,  a past president of the American Health Information Management Association.

Organizations should have a reporting mechanism in place for noncompliance reports. It’s better that they get the reports and fix problems instead of forcing noncompliance reports to go to healthcare payers or government agencies.

Noncompliance may not always include fraud but it still needs to be addressed. Among the reportable issues Dunn lists are:

  • Documenting services long after the service was provided
  • Failure to code to the highest level of specificity supported by documentation
  • Leading physician queries
  • Adding codes that change the diagnosis-related group (DRG) to a higher reimbursement level and are not supported by documentation.

Coders should have the option to report noncompliance anonymously or not. And they need to be protected. It’s better to fix compliance issues than pretend they don’t exist.

How to outsource ICD-10 coding and get high quality

As healthcare organizations prepared for ICD-10 implementation, they trained medical coders to work with the new code sets. Those coders who learned ICD-10 coding became more valuable and encouraged them to change jobs.

For Athens Regional Medical Center (ARMC) in northeast Georgia, this created a shortage of ICD-10 expertise. That led ARHS to turn to outsourcing vendors to maintain quality and productivity during the ICD-10 transition.

According to Penny Bond, director of HIM at ARMC, this wasn’t as easy as writing a check. There were several factors credited with keeping productivity and accuracy high that included:

  • ARMC worked with two outsourcing agencies to supplement in-house medical coders.
  • All in-house and outsourced coders were managed as one team.
  • Clear goals were set for everyone.
  • Education was shared among all medical coders.
  • Funs activities were available to all medical coders.

Bond wrote all medical coders were managed the same despite their employment status. This required work and leadership beyond writing a check.

The medical coders became a hybrid coding partnership that worked for everyone.

Don’t be afraid to use an unspecified ICD-10 code

If something bad happened to anyone on Friday, it would be tempting to blame injuries on the bad luck of Friday the 13th. But that’s not recognized as an external cause  in the ICD-10-CM codes.

Even if the patient has triskaidekaphobia (fear of the number 13) or paraskevidekatriaphobia or friggatriskaidekaphobia (fear of Friday the 13th), the best you’re going to do is F40.9 (phobic anxiety disorder, unspecified).

Here’s a round up of recent articles and posts on how to code diagnoses and procedures in ICD-10:

This is a weekly feature that I use to highlight practical tips on how to use and understand ICD-10-CM/PCS codes. Please let me know of any other sources that I can include.

CMS: PQRS penalties are suspended because of ICD-10 updates

The Centers for Medicare and Medicaid Services (CMS) reminded the healthcare industry this week that they will not apply 2017 or 2018 Physician Quality Reporting System (PQRS) penalties in some cases.

Healthcare providers may not have been able to satisfactorily report on quality data in the first three months of the ICD-10 code updates. CMS was not able to process data reported on certain quality measures for the 4th quarter of calendar year 2016.

More Information:

ICD-10 coding is only as good as the documentation

It’s worth emphasizing that healthcare providers cannot code what has not been documented in the clinical notes or reports. Even when it means leaving money on the table.

Dave Pearson cites a study in the Journal of the American College of Radiology that found incorrectly coded ultrasounds were being reimbursed at a lower rate than they should have been.

The problem came from missing information in radiology reports from complete abdominal ultrasound exams. Because the information was missing, the exams were coded as limited.

But when custom report templates were created that prompted clinicians to document completely, reimbursements went back up.

This is not upcoding. This is coding that captures what is allowable and due the healthcare providers.

The study authors, Kristine Pysarenko, MD, Michael Recht, MD, and Danny Kim, MD, noted that “ICD-10 has made it harder than ever to ensure correct and accurate coding.”

Perhaps some ICD-10 compliant electronic health records (EHRs) have made it harder to ensure complete documentation.

ICD-10 updates revised more than just code sets

On Oct. 1, 2016, U.S. healthcare organizations revised the ICD-10-CM/PCS codes they were working with. This required more training and system updates.

But the actual codes weren’t the only things that changed. The coding guidelines were revised also. The guidelines explained how the ICD-10 codes were to be applied and defined key concepts.

The Centers for Medicare and Medicaid Services (CMS) has the new guidelines online:

Tina Brown, director of operations for coding and revenue cycle at ELIPSe, Los Angeles, told Revenue Cycle Advisor that the ICD-10 guideline changes brought greater clarity. But other changes were a bit trickier to grasp.

The guideline changes include terminology updates. That can create confusion if clinicians cling to the older terms and can’t find those terms in the ICD-10 codes. Or they may continue to use outdated terminology in documentation.

These coding and guideline updates will be the new normal. Medical knowledge is always evolving. ICD-10 coding and guidelines need to keep up with it.

Take a quick refresher on ICD-10-CM/PCS coding

Here’s a round up of recent articles and posts on how to code diagnoses and procedures in ICD-10:

This is a weekly feature that I use to highlight practical tips on how to use and understand ICD-10-CM/PCS codes. Please let me know of any other sources that I can include.

Three guidelines that can aid coding compliance

Medicare and private healthcare payers are increasing scrutiny of claims from ambulatory surgery centers (ASCs). According to Alison Kuley writing for Becker’s ASC Review, that scrutiny has meant that some ASCs gave back reimbursements to the payers.

Cost cutting is a part of the reason for increased scrutiny. Detecting identity theft and fraud also are driving these costly reviews. While Kuley’s report focused on ASCs, this should be a concern to all healthcare providers submitting medical claims for reimbursements.

In a nutshell, healthcare providers should at least follow these guidelines:

  • Do not bill if there is no documentation for the procedure.
  • Pay attention to healthcare payer guidelines when using unlisted or nonspecific codes.
  • Collaboration can be key. For example, medical coders should be able to consult physicians when diagnoses or procedures are in doubt.

Most effective is adequate education and training. That doesn’t apply just the medical coding and billing staff. All clinicians need to understand proper documentation and compliance issues to protect their employers from costly reviews.

Three things that can affect ICD-10 coding in 2017

U.S. healthcare has been using ICD-10-CM/PCS coding for more than a year so there doesn’t seem like anything new could happen. But there are three things that might make their marks on the code sets.

New coding updates

Obviously any ICD-10-CM/PCS updates are considered developments. But I’m interested in seeing how the updates are handled.

Healthcare providers are going to panic because the 2017 ICD-10 updates set them back (which we do not know yet) or they will yawn because they have coding systems that tackle the new codes without creating hassles.

If the latest updates don’t throw healthcare providers out of sorts, it’s possible physicians will appreciate the new granularity they wanted to be able to document on medical claims.


There are reports that diagnosis coding productivity is returning to ICD-9 levels. The procedural coding levels are another matter. But that is a challenge for hospitals that have resources to throw at the problem.

How productivity levels for clinicians and medical coders trend will greatly affect how ICD-10 coding is perceived.

Soon-to-be President Donald Trump

This isn’t meant as an insult, but it is doubtful that President-elect Donald Trump knows what ICD-10 coding is. Very few successful and intelligent people outside of healthcare do. So he probably has no opinion on what should happen to it.

But he has nominated Rep. Tom Price to lead Department of Health and Human Services (DHHS). Price never has been a fan of ICD-10 coding. He has co-sponsored anti-ICD-10 bills.

But it’s hard to imagine Price asking Congress to revert U.S. healthcare back to ICD-9 coding. That would create more havoc and cost than the original ICD-10 transition. Besides, he’s going to be busy reimagining Obamacare and reforming Medicaid.

By the way, I predict in 2018 I will have to write posts explaining why we still have ICD-10 coding despite the repeal of Obamacare.

But whatever Trump and Price come up for healthcare, they’re going to want to target waste and fraud. Politicians love to campaign against waste and fraud. So it would be a great idea to create a healthcare system that pays for benefits by eliminating waste and fraud.

Someone could persuade Trump that ICD-10 coding will be a great tool to identify the waste and fraud. That could be more persuasive than physician complaints about how onerous and burdensome this ICD-10 mandate is.

If Trump promises the best electronic health records (EHRs) and massive reductions in healthcare regulations and red tape, ICD-10 will work beautifully.

This could be the year that great change comes to healthcare, and ICD-10 coding stands a chance of being part of that.

By the way, ICD-11 still is on the way

Not many healthcare professionals really enjoy being in a constant state of transition. Bureaucrats seem to be changing things all the time.

Just when physicians think they have a handle on ICD-10 coding, the federal government releases thousands of new and updated codes.

The World Health Organization (WHO) is supposed to present the ICD-11 code set to the world in 2018. That doesn’t mean that U.S. healthcare will switch from ICD-10 to ICD-11 in 2018.

But ICD-11 won’t be ready to use then. We had to add ICD-10 codes to the code set to work with our reimbursement and reporting needs. That’s why there so many more ICD-10-CM codes than ICD-10 codes.

How long do you think it will take for the U.S. government to come up with ICD-11-CM/PCS?

I used to think the U.S. healthcare system could have usable ICD-11 codes in 2020. But I do not believe we can get through the regulatory process by then. So relax, we won’t have ICD-11 to kick around anytime soon.

It’s a database, not a list

By the way, the WHO is building a database. The ICD-11 content model is described as:

  • Represents ICD entities in a standard way
  • Allows computerization
  • Each ICD entity can be seen from different dimensions or “parameters”. E.g. there are currently 13 defined main parameters in the content model to describe a category in ICD.
    1. ICD Entity Title
    2. Classification Properties
    3. Textual Definitions
    4. Terms
    5. Body System/Structure Description
    6. Temporal Properties
    7. Severity of Subtypes Properties
    8. Manifestation Properties
    9. Causal Properties
    10. Functioning Properties
    11. Specific Condition Properties
    12. Treatment Properties
    13. Diagnostic Criteria
  • A parameter is expressed using standard terminologies known as “value sets”


It’s complicated but not too complicated for the level of technology in most medical practices and hospitals. Medical coders can still use paper books to look up codes. Digital might be faster. But most healthcare professionals can relate to ICD-10 coding. It’s basically more of the same thing they’re used to.

How to hijack the ICD-11 development process

In life, we have two choices:

  1. We can let things happen to us.
  2. We can make things happen for us.

And the WHO gives us both options when it comes to ICD-11 codes. We can wait for them to release it in 2018.

Or we can become part of the process and help create the ICD-11 code database. The process allows for collaborators to:

  • “Make comments”
  • “Make proposals”
  • “Propose definitions of diseases in a structured way”
  • “Participate in Field Trials”
  • “Assist in translating ICD into other languages”

ICD-11 may be a work in progress but we have a chance to work on it and help mold it into something more useful in the United States.

Preventing ICD-10 denials comes down to knowledge

The question of how ICD-10 implementation — and the safe harbor and the 2017 updates — affects claim reimbursements and denials is worth debating. But what’s more important to healthcare professionals should be how ICD- 10 coding is affecting their organization.

That’s going to require data. In other words, organizations need to track how their medical claims are doing. Hopefully the billing systems can track:

  • Days in accounts receivable by healthcare payer
  • Denial rates
  • Amount of reimbursements denied
  • If reimbursements match the contracted rates

Even more hopefully, these organizations have some metrics from the past couple years — pre-ICD-10 metrics and pre-ICD-10-update metrics. Those metrics can set expectations that can be compared to what is happening currently.

To get denials down, Medical Economics has four tips to help prevent ICD-10 denials:

Verify EHR coding

Trusting electronic health records (EHRs) should be automatic. But the ICD-10 code selection could be based on mappings that don’t result in the most specific or correct ICD-10 code needed.

Double check the ICD-10 codes used most often or are responsible for the most revenue (This information is available if data has been collected in the past couple years) to make sure the best ICD-10 codes are used.

Customize forms

Check encounter forms and superbills. Make sure they have the best options for diagnoses (Again, historical data) and include details such as encounter and laterality.

Document well

Everyone should know that medical coders are expected to assign the most specific ICD-10 codes possible. What’s possible is defined by the clinical documentation. That means specificity starts with documentation.

And the documentation needs to support medical necessity to make sure healthcare providers can justify they level of reimbursement they are due.

Know healthcare payer policies

It’s not news that there are differences in what they cover and how they reimburse. There may be differences in the modifiers required. Knowing what healthcare payers want is the kind of knowledge that is most important for preventing ICD-10 denials.

Preventing ICD-10 claim denials requires knowledge about what healthcare payers expect, strong documentation and correct, accessible information.

The top 3 ICD-10 developments of 2016

It didn’t look like 2016 was an exciting year for ICD-10 coding. After all, 2015 was the year it became law of the land. So listing 2016’s ICD-10 developments seemed like a stretch. But there were three things worth noting from 2016.

U.S. healthcare yawned

We started 2016 with three months of ICD-10 coding under our belt. Any moment we expected to find out if ICD-10 implementation was killing medical practices or heralding a new era of healthcare. But we never got enough data to make a judgment.

No, it wasn’t perfect. And physicians found reasons to complain fairly. But there didn’t seem to be any reason to get excited about ICD-10 coding.

Oct. 1, 2016

And things didn’t get any more exciting Oct. 1. That was the deadline for two significant changes:

  1. The so-called safe harbor for less specific ICD-10 coding ended.
  2. Thousands of new, updated and deleted ICD-10 codes hit the books.

So far, only crickets are the only sound being made. The impact of those two developments are not showing up in data. Maybe they won’t.

Personally, I feel the Centers for Medicare and Medicaid Services (CMS) agreement to not flag ICD-10 codes in the same that could have been more specific in some uses was underwhelming. I didn’t see it adding up to a lot of help.

Maybe it did. Maybe an unofficial laxness in specificity enforcement helped ease ill-prepared healthcare providers into ICD-10 coding. Maybe it’s all good now. Which could be why U.S. healthcare yawned again.

Donald Trump elected president

We will get into this more next week when we look at 2017. But Donald Trump’s election is going to have an effect on U.S. healthcare.

But something else significant happened. Data journalism became a thing that attempted to sum up the presidential race in a number. That’s why we got smart people telling us that Hillary Clinton had a 73 percent chance of becoming president.

We could debate the value of this kind of dashboardization. But we always love to boil down complex situations to numbers. Vehicle gas mileage. Camera megapixels. Computer RAM. Claim denial rate.

The presidency was another complex situation that we wanted summed up in one tweetable number. Claim denial rates is another.

Maybe we shouldn’t have yawned.

An old problem with DRG assignments has ICD-10 repercussions

The Office of Inspector General (OIG) is applying greater scrutiny to a couple DRG assignments.

One focuses on mechanical ventilation. An OIG audit found a 95 percent error rate in Medicare billing from 2009 to 2011. That isn’t an ICD-10 problem. The problem has existed long before ICD-10 implementation. But if there is greater scrutiny of medical ventilation diagnoses, healthcare providers need to make sure they nail the right assignments of ICD-10 codes and DRGs.

It underscores the need for healthcare providers to continue training. Their medical coders need to know more than just new codes. They need to understand the rule and guidelines. The correct application is as tricky and important as it every was.

How ICD-10 codes could impact population health

If you’re trying to figure out how ICD-10 codes are going to do anything for patients, take a look at what Massachusetts Virtual Epidemiologic Network (MAVEN) is doing to create an interoperable population health management system to help HIV patients.

They want to use EHR data to identify HIV patients who are at risk of not keeping up with treatments. “Reconciling lab results against clinical data can help to determine whether a patient is maintaining his or her treatment protocols. If not, public health field workers conduct outreach and encourage patients to reengage with their regimens,” according to Jennifer Bresnick at Healthcare IT Analytics.

There are quite a few challenges here. The biggest would be the variety of EHR systems and standardizing the data. That’s a common challenge these days.

Also, patient encounter data becomes important. “Each clinic also has unique protocols for documenting the type of encounter and issues addressed during an individual consult, many of which may not rely on standardized clinical coding systems like ICD-10,” Bresnick writes.

This is pretty important since the whole effort is to keep patients engaged with the clinics.

Love or hate ICD-10 granularity, it does provide some standardization. That’s what’s important when trying to spot problems and provide solutions.

So documenting details won’t cure a patient or relieve their pain in that moment of clinician interaction, it could help identify problems that are likely to come. That can give healthcare providers opportunities to prevent complications or offer treatments.

ICD-10-CM codes that are not on anyone’s Christmas list

A good Christmas would be one when Santa Claus comes to the chimney, not the waiting room. But if you see a medical claim for Nicholas “Santa” Claus, you might be using these diagnoses:

  • Ankle sprain – S93.402A, Sprain of unspecified ligament of left ankle, initial encounter
  • Fall from roof – W13.2XXA, Fall from, out of or through roof, initial encounter
  • Smoke exposure – X02.1XXA, Exposure to smoke in controlled fire in building or structure, initial encounter

And here are a few more holiday diagnoses:

  • Y92.59 – Injury at shopping mall: No sweat. You saw this on Black Friday.
  • R10.13 – Indigestion: Some people haven’t taken a break from eating since Thanksgiving.
  • A051 — Botulism food poisoning: Any canned ham recently?
  • V80.1 – Injury as occupant of animal-drawn vehicle: Nothing says Christmas like a ride in a horse-drawn sleigh. The North Pole Emergency Center probably has a great deal of experience with this one. Reindeer, you know.
  • W55.32XA  Struck by other hoof stock, initial encounter: Like I said. Reindeer.
  • W00 – Fall due to ice and snow: One person’s white Christmas is another patient’s visit to the ED.
  • W14— Fall from tree: The problem with really big Christmas trees is that it gets tricky putting a star on top.
  • T33.53 – Superficial frostbite of finger: Some people just don’t think gloves are necessary.
  • T28.0XXA – Burn of mouth pharynx, initial encounter: When the hot chocolate is really hot— too hot to drink.
  • X08.8XXA — Exposure to other specified smoke, fire and flames, initial encounter: There are candles all over the place. So be careful.
  • W29.0XXAContact with powered kitchen appliance, initial encounter: Cookie-making injuries aren’t just caused by hot cookie trays. Some people get their hands just a little too close to the mixers while making cookie dough.
  • W262XXA — Contact with edge of stiff paper: Paper cuts. If the scissors don’t get you, the wrapping paper will.
  • Z72.820 – Sleep deprivation: How late was the patient up Christmas Eve assembling children’s toys?
  • Z62.891 –  Sibling rivalry: This can be worse than the fights with the in-laws during Thanksgiving.

I hope you’re having a good holiday and able to avoid these diagnoses.

Why small practices may be struggling after ICD-10 grace period

There’s no evidence that small medical practices and independent physicians are having problems since the grace period on ICD-10 specificity ended Oct. 1.

Since it the only applied to Medicare fee-for-service claims from physicians billed under the Medicare Fee-for-Service Part B physician fee schedule, the impact should be limited.

But Debi Primeau, president of Primeau Consulting Group, told Health Data Management that smaller physician groups and medical practices were more likely to use unspecified ICD-10 codes instead of more specific and accurate ICD-10 codes.

There’s no evidence that is true though.

Even so, it’s not a bad idea to take Primeau’s advice and audit the mix of ICD-10 codes to see how specific ICD-10 coding was in the first year.  That could lead to an increase in reimbursements and a denial prevention strategy.

Earlier this year, Primeau reviewed eight potential denial data points:

  • Sequencing: Review the ICD-10-CM guidelines to make sure right ICD-10 codes are chosen for the primary diagnosis.
  • Aftercare: The Z codes designate specific instances of aftercare. But usually it is correct to use the injury ICD-10 code with the seventh character designating a subsequent encounter.
  • Unspecified codes: Yes, they do exist. But will auditors start looking for them?
  • Laterality: It’s great that ICD-10 codes allow to differentiate between the left and right sides of the body. But sometimes one bilateral code is needed instead of two diagnosis codes to designate the left and right side as affected.
  • Hip and knee replacements: Use ICD-10-PCS codes for removal and replacement.
  • Missing codes: This may get some physician push back. But the guidelines require supporting diagnoses in some cases.
  • Medical necessity: This is going to require keeping up with local coverage determination (LCD) and national coverage determination (NCD) updates.

This is the kind of data that healthcare payers have been analyzing that might drive denial decisions. Medical practices should use their data to find any problems first.

How to strengthen ICD-10 implementation

There is always room for improvement. And healthcare providers can improve their coding productivity and revenue cycles.

Often gains can be found in clinical documentation improvement (CDI) initiatives, according to Mel Tully of Nuance. There are two ways healthcare providers can overcome deficiencies:

  1. Continue to educate staff. This includes training sessions and practical exercises.
  2. Let the medical coders help identify where documentation needs improvement.

This is also a good time to start looking for ways to use the data gathered from ICD-10 codes. For example, Tully suggested looking at complications involving diabetes. The data could support a specialist that could educate staff and patients about diabetic risk factors and lead to healthier outcomes.

It certainly looks like ICD-10 education is just as important now as before Oct. 1:

  • Assess how medical coders are doing with the ICD-10 claims and schedule training as needed.
  • Physicians need to keep working with clinical documentation specialists to make sure they capture the correct details for ICD-10 codes.

The more proficient everyone gets, productivity should rise and confusion should fall.