Cracking the ICD-10 Codebook for Audiologists

January 2015

Tamala S. Bradham

The International Classification of Diseases (ICD) is the standard diagnostic tool used for clinical purposes, epidemiological research, and global health management (World Health Organization [WHO], 2014a). ICD allows administrators, researchers, and health care professionals to monitor and track mortality and morbidity, incidence and prevalence of diseases, and other health data, as well as reimbursement for services rendered. Since 1979, the United States has been using the ninth version (ICD-9-CM [Clinical Modification]), although there have been multiple attempts to implement ICD-10-CM in the United States. The current ICD-10 compliance deadline is October 1, 2015. The new ICD-10 will include the ICD-10-CM and ICD-10-PCS (procedure coding system). The ICD-10 is owned by WHO. The clinical modification was developed by the Centers for Disease Control and Prevention (CDC) for use in the U.S. health care industry. The procedure coding system (i.e., ICD-9-PCS and ICD-10-PCS) was developed by the Centers for Medicare & Medicaid Services (CMS) for use in the United States for inpatient hospital settings only. Also of importance, in May 1990, ICD-10 codes were endorsed by the Forty-third World Health Assembly and have been adopted by most developed countries. The 11th version, ICD-11, is now being prepared and will be finalized in 2017.

Transitioning to ICD-10 offers the U.S. health care system several benefits. In ICD-9, there is a lack of clinical accuracy, a limited number of available codes, and a restrictive coding structure (CMS, 2014). Furthermore, the United States is not able to compare mortality and morbidity data globally, as most developed countries already employ ICD-10 (American Academy of Professional Coders [AAPC], 2014a; Bowman, 2014). Transitioning will result in moving from 14,025 to 69,823 diagnosis codes and from 3,824 to 71,924 procedure codes (CDC, 2013).

ASHA has developed a number of resources to help audiologists transition to ICD-10, including an ICD-9 to ICD-10 online mapping tool that allows one to enter an ICD-9 code, which is then mapped to the appropriate ICD-10 code(s). ASHA also has mapping spreadsheets for audiology codes and a list of ICD-10 audiology codes. To learn more about ICD-10 for audiology, please visit ASHA's website.

ICD-10 and Documentation

In surveys of health care leaders on major IT challenges in health care organizations over the next 3 years, ICD-10 implementation is listed as the number one concern and documentation is listed second (Letourneau, 2013). Nachimson Advisors (2011) estimated increased documentation costs associated with an ICD‐10 implementation ranging "from $44,000 for a small practice to $1.76 million for a large practice" (p. 5).

For ICD-10 coding, thorough, timely, and succinct documentation of a patient's visit will be necessary to minimize claim denials (Carr, 2013; Hertz, 2013; Husty & Newell, 2013; Leenheer, 2012; Levy, 2013). It will be essential for audiologists to document using very specific diagnostic and treatment terminology. Some states or payers may require greater specificity, laterality, stages of healing, cause and location of the injury, treatments tried, and acute or chronic disease state, to name a few examples in clinical documentation (AAPC, 2014b; see Appendix A for an example).

Hertz (2013) reported that health care providers are not currently documenting information that will be necessary for appropriate ICD-10 coding, which will ultimately affect reimbursement under the new codes. With the current ICD-9 system, the most common reasons for improper payments during a recovery audit (by recovery audit contractors [RAC]) were (1) services did not meet medical necessity criteria, (2) services were incorrectly coded, and (3) supporting documentation that was submitted did not support the ordered service (CMS, 2012). It is plausible that, with ICD-10 coding, RAC may see a rise in incorrect coding and insufficient documentation. A field study by the American Health Information Management Association (AHIMA; 2003) found that, although ICD-10-CM codes could be applied to medical records without any changes to documentation practices, coding specificity would be improved if documentation was better.

What Does This Mean for Audiology Practices?

To help audiologists be successful with the transition from ICD-9 to ICD-10, ASHA (2014a) developed an ICD-10-CM Preparation Checklist. Checklist items include (1) training, (2) better documentation, and (3) monitoring and communicating.

Training

Clinical and administrative staff will require significant time learning new codes and work flows. The learning curve is expected to be steep for both clinicians and administrative staff (AAPC, 2014b). AAPC reported that inadequate training could result in "reduced productivity levels for as long as 6 months due to increased re-work for denied claims, adjustments, and pended claims, and coders directing an increasing amount of queries to physicians when documentation is not adequate to support the higher level of specificity required with ICD-10" (AAPC, 2014b, p. 9). Having a thorough understanding of the ICD-10 codes will be essential, especially because many practices do not have coders to determine which codes would maximize reimbursement and meet compliance standards. It is also important to know that ICD-10 codes for hearing loss are very different than ICD-9 hearing loss codes. For example, for a sensory hearing loss, ICD-9 codes used would have been 389.11 for bilateral sensory hearing loss or 389.17 for unilateral sensory hearing loss. For ICD-10, the clinician will use H90.3 Sensorineural hearing loss, bilateral or H90.41 Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side if the patient has hearing loss in the right ear and normal hearing in the left ear or H90.42 Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side if the hearing loss is in the left ear and there is normal hearing in the right ear. If the patient has a different type of hearing loss in each ear, then the clinician will use H90.5 Unspecified sensorineural hearing loss and H90.8 Mixed conductive and sensorineural hearing loss, unspecified if the patient has a sensorineural hearing loss in the right ear and a mixed hearing loss in the left ear. There is a proposal before the National Center for Health Statistics to add new codes for when an audiologist uses "restricted hearing on the contralateral side"; however, there will be no revisions until 2016 at the earliest.

Documentation

Based on case history and presenting complaints, audiologists need to determine what test(s) will address the reason(s) for the patient's visit or what activities will address the treatment goals/plan. The procedures or interventions performed and billed should be based on the patient's presenting complaints and should be medically necessary. The diagnosis should support the patient's complaint(s) and the procedure(s) performed. In the event the test results are normal, the diagnosis code should report the signs and symptoms of the patient's complaint(s).

Documentation should include the following components:

  1. date and time of when the evaluation and treatment were performed,
  2. history/background and presenting complaints,
  3. procedures and activities to be performed to address the complaints/goals,
  4. assessment/interpretation of the evaluation and treatment,
  5. recommendations/plan of care to address the findings,
  6. signature of the provider.

When coding for diagnosis, audiologists should use as many ICD-10 codes as necessary to substantiate medical necessity for the visit. If the payer requires Z codes, here are some case examples for how these can be used when test results are normal:

Example 1: Child comes in for a hearing test prior to a speech-language evaluation. The parent does not have any concerns about hearing but does not know why the child is not talking. The audiology test results are normal. Use F80.1 Expressive language disorder.

Example 2: Toddler passed newborn hearing screening but has a risk factor. Toddler comes in at 12 months for audiology follow-up testing.

Scenario 1. Test results are normal. History reveals a family history of congenital hearing loss. Use Z01.10 Encounter for examination of ears and hearing without abnormal findings AND Z82.2 Family history of deafness and hearing loss.

Scenario 2. Test results are inconclusive. History reveals that the toddler underwent ECMO. (OAEs and tympanograms are normal; sound field at 2,000 Hz is at 20 dB HL.) Use Z01.10 Encounter for examination of ears and hearing without abnormal findings AND Z92.81 Personal history of extracorporeal membrane oxygenation (ECMO).

Scenario 3. Test results are inconclusive. History reveals prematurity and low birth weight. (Note: Documentation would need to specify weight and gestational age. OAEs are normal; tympanograms are flat; sound field at 2000 Hz is at 30 dB HL.) Use Z01.110 Encounter for hearing examination following failed hearing screening OR Z01.118 Encounter for examination of ears and hearing with other abnormal findings AND P07.36 Preterm newborn, gestational age 33 completed weeks AND P07.17 Other low birth weight newborn, 1750-1999 grams.

For assistance with mapping ICD-9 codes to ICD-10 codes or vice versa, please refer to ASHA's Mapping Tools (2014b) as well as ICD-10-CM Diagnosis Codes Related to Hearing and Vestibular Disorders for assistance with learning the code (2014c). With extensive training and thorough documentation, audiologists should be well-positioned to remain viable during the transition from ICD-9 to ICD-10.

Monitoring and Communicating

To date, there have been no studies that have specifically evaluated the denial rates and timeliness of reimbursement for services in audiology practices with ICD-10 implementation. Audiology practices will more than likely experience an increase in denial rates and prolonged duration before receiving reimbursement as the health care industry works through the transition. Thus, to manage ICD-10 implementation and cash flow, it will be necessary to have oversight of the denials using a monthly scorecard system that tracks completed tasks associated with ICD-10 and number of denials (HFMA, 2013). Health care systems also will need to develop a process for managing errors and resolving vendor issues (CMS, 2014).

With ICD-10 implementation, sharing success stories, highlighting people who have been "champions" in the process, and being transparent with staff and patients on how the health care system is handling ICD-10 will be pivotal to engaging people in the process and minimizing financial impacts to the system. Audiologists cannot overcommunicate about this system change.

Final Thoughts

At some point, the United States will transition to a new ICD system. It is essential for audiologists to learn as much as they can about ICD-10 codes, review their current documentation systems and determine how to prepare for potential changes, and have a dashboard/monitoring system to keep track of the claims and denials for proactively managing this transition. ASHA offers, in addition to previously mentioned resources, a checklist to determine ICD-10 readiness.

To minimize delayed payments and to maximize reimbursement with ICD-10, Leenheer (2012) recommended that clinicians (1) complete an assessment of existing documentation and develop an action plan from the findings, (2) implement an easy-to-use electronic documentation system, and (3) obtain education and ongoing trainings. Documentation of the patient's visit is "key to a successful transition to ICD-10" (Leenheer, 2012, p. 112). There are several tools and training materials available to help with this transition (ASHA, 2014a, b, c).

The benefits of ICD-10 include (1) improved quality of care; (2) potential cost savings from increased accuracy of payments and reduction of unpaid claims (i.e., fewer rejected claims); (3) improved tracking of public health data; and (4) upgrades to improve IT data integrity, fraud detection, and cost analysis capabilities. While this change to ICD-10 does come at a price, many of the projected financial challenges can be mitigated with proper planning, training, and IT management. The potential benefits over the long term cannot be overlooked.

Acknowledgment

Much appreciation is extended to the following people who have taught me a great deal about ICD-10 codes: Mary Sue Fino-Szumski, Ronald Kintz, Cathy Lackey, Tammy Reno, Shawn Scarbrough, and Lori Sells.

About the Author

Tamala S. Bradham, PhD, CCC-A, is a quality consultant in the Center for Quality, Safety, and Risk Prevention at Vanderbilt University Medical Center, where she is at the forefront of health care reform, evidence-based practices, and population health and practice management. Her research interests include auditory, speech, and language outcomes in children with hearing loss; cochlear implants; discharge practices; and family-centered practices in health care. Formerly, she was on the faculty at the Vanderbilt Bill Wilkerson Center, where she was the associate director of services at the National Center for Childhood Deafness and Family Communication. In this role, she developed and managed services for children with hearing loss, which included serving on the pediatric cochlear implant team, providing audiologic (re)habilitation and speech-language services, and teaching at the Mama Lere Hearing School. She is the former coordinator for ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood. Contact her at tamala.bradham@vanderbilt.edu.

References

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