As of today, the CMS is still planning on moving to ICD-10 codes on October 1, 2015. Will you, in the imaging world, be ready? While physicians and clinical staff will not be necessarily responsible for correct coding, the documentation that they do will greatly affect the way diagnoses and procedures are coded, and as a result, the way facilities and practitioners are reimbursed. It “pays” to take a few minutes to be sure that the documentation that you produce is clear, complete and detailed.
Why is CMS going to ICD-10? In general, the new codes are more complete and have greater specificity. This system is easily expandable as new procedures become introduced, and the multi-axial structure of the system makes it easier to analyze. Finally, the use of standardized terminology makes it much easier to use, once the initial training is completed and you understand the way it works.
There are of course thousands of new diagnosis codes, which will not be discussed here, but there are also thousands of new procedure codes. Each code will now contain seven characters (as compared to the five now available in current CPT codes). There is a separate section for imaging procedures, which are then divided into body system, types of procedures, body parts, whether or not contrast is used, and two more spaces for qualifiers to further define the procedure. Interventional radiology codes will be found under the Medical Surgical section, as will cardiac procedures.
So, what does all of this mean to us? For ICD-10 readiness, we must make sure that our documentation includes all of the appropriate information: What was the procedure? Where was it performed? Was contrast utilized? Was angioplasty performed? On how many sites? Was a filter or a stent placed? Where was it placed? Was the patient monitored? These are just some of the examples of documentation that must be included in order for the appropriate codes to be assigned to the patient’s account.
Stay tuned to the Medical Imaging Talk blog where I will address what type of documentation can be used to fulfill requirements in a cardiac catheterization procedure.