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Under ICD-10, submitting compliant and accurate claims and minimizing the negative impact to clients’ cash flow were concerns shared by all those in the coding and medical billing community. While the transition has been relatively smooth as it pertains to our internal operations, there have been unanticipated challenges on the payor side. One area that appeared to be significantly affected was radiology.

Diagnosis coding for diagnostic testing has dramatically changed now that ICD-10 has been implemented. The requirement to report diagnoses with a higher level of specificity has resulted in radiologists having to expand on the medical history and indications for an exam, plus include much more detail in their findings, such as laterality and specific anatomical location.

This task is especially difficult in radiology due to the industry’s reliance on the ordering physician to supply necessary documentation regarding the reason for the study and patient history. In the absence of findings, the reason for the test, including signs and symptoms, are reported to the payer. Many of the standard indications historically used when ordering a diagnostic test, such as “pain” or “cough,” in ICD-10 are coded using an unspecified code. It is imperative that the treating physician provide to the radiologist the signs and symptoms that prompted the order, especially in the specialty of radiology, where many times an exam will produce no definitive findings.

Radiology is a specialty that at times will produce claims with unspecified diagnoses, and the Centers for Medicare & Medicaid Services (CMS) has confirmed the accuracy of this, stating that “when sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code.”

Although payers have indicated that unspecified codes could result in denials, we anticipated that this wouldn’t cause immediate problems after CMS guidance was published indicating that for 12 months after ICD-10 implementation, Medicare contracts would not deny claims based solely on the specificity of the ICD-10 diagnosis code. Yet unfortunately, this was not the case.  

Based on the information published by CMS, the assumption was that all LCD information would be translated from ICD-9 to ICD-10, with no changes coming to any of the previously approved medical necessity guidelines. We found this not to be the case when certain previously approved indications under ICD-9 were no longer included in the covered ICD-10 diagnoses. It appeared that in some instances, codes had been excluded due to the fact that they were unspecific. This obvious error affected a number of LCDs related to radiological procedures and clearly presented a potentially significant financial impact on providers.

Our initial encounter with this issue was in early October, with the denial of noninvasive peripheral venous study services when reported with leg/arm swelling under LCD L34229 to our MAC (Noridian Healthcare Solutions). Swelling is often a symptom associated with deep vein thrombosis (DVT), and was previously an approved reason for diagnostic testing under the Noridian LCD. Although ICD-10 directs leg/arm swelling to be coded to M79.89 (Other and unspecified soft tissue disorders, not elsewhere classified), it appeared that due to M79.89 being unspecified/not elsewhere classified, the code was omitted from being covered after the LCD was translated to ICD-10. 

As these issues were identified, we quickly submitted an LCD reconsideration to Noridian, which recently recognized the validity of M79.89 under LCD L34229 and made the appropriate updates. We have found that the issue of missing unspecified codes after LCD translation to ICD-10 has affected a number of other LCDs for this carrier as well, such as: L34212 (Cardiovascular Nuclear Medicine: Myocardial Perfusion Imaging and Cardiac Blood Pool Studies) and LCD L34317 (Chest X-Rays). These missing indications, which previously supported radiological studies, can be significant in their impact to provider reimbursement, especially if the indication is one seen often as a regular sign or symptom of a condition. 

Ultimately, strong documentation from both the radiologist and the ordering physician is essential in order for providers to be successful under ICD-10. Ordering physicians need to be aware of their impact on the radiologist’s ability to appropriately bill for ordered services. Close and timely review of denials related to ICD-10, especially those tied to medical necessity and LCDs, is essential to ensuring stable cash flow through this transition.

Any variations seen after LCD translations should be appealed to attempt to limit future denials and get payer guidelines appropriately updated.

About the Author

Allison Morgan, MS, CPC, CPCO, is a Compliance and Education Specialist with Medical Specialties Managers, Inc., a comprehensive revenue cycle and practice management organization, located in Orange, California. Combining her background in instructional design and technology, along with her experience in revenue cycle and coding, she provides compliance and education services for MSM.

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