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The new year for diagnosis codes begins Oct. 1, 2016. That date also marks the end to the moratorium on new codes that has been in place since Oct. 1, 2011. For the upcoming year, there are 1,974 code additions, 311 deletions, and 425 revisions. 

In addition to many new, more specific fracture codes, the following additions will be of particular interest to radiology. New codes have been added relating to the following areas:

  • Gastrointestinal stromal tumors (seven new codes)
  • Cerebral infarction due to bilateral artery thrombosis or embolism
  • Aneurysm of vertebral artery and basilar artery
  • Dissection of arteries in the upper and lower extremity, and basilar artery
  • Specific types of acute vascular disorders of the intestines (18 new codes replace one generic code)
  • Sacral dimple
  • Pain in hand joints
  • Cervical disc disorders
  • Periprosthetic fractures
  • Laterality of ovarian and fallopian tube diagnoses
  • Abnormal radiologic findings on diagnostic imaging of urinary organs.

Putting the Nix on Non-specific Codes

In July 2015, the Centers for Medicare & Medicaid Services (CMS) announced that during the first year of ICD-10-CM, Medicare Administrative Contractors (MACs) would not deny claims based solely on the specificity of the diagnosis code. Many practices interpreted this as approval to ignore the specific ICD-10-CM codes and to continue to report non-specific codes.  

Consequently, some facilities and practices are now struggling to put processes in place to make sure that specific clinical indications are obtained. Many of the new code revisions are more specific than the initial diagnosis codes.

However, if you looked only at radiology claims, you would think that there are many thousands fewer than the 71,486 codes available. Radiology claims are still often coded with non-specific codes. For instance, most exams for female patients with breast cancer are assigned the non-specific code C50.919: malignant neoplasm of unspecified site of unspecified female breast.  

Another example is “injury.” Instead of coding a non-specific injury code, the type of injury (contusion, sprain, laceration) or symptom (pain) should be documented and coded. Reports for imaging for injuries also should indicate whether the exam occurred during the initial treatment phase or subsequent healing phase – or whether it is a sequela of a previous injury.

When there are different types of a disease, the specific type should be documented, if known. For example, among the new codes are 18 for acute pancreatitis, differing between type (idiopathic, biliary, alcohol-induced, drug-induced, other, and unspecified) and whether there is necrosis and infection.  

Laterality should be documented when appropriate. Many diseases and injuries have separate codes for left, right, and bilateral indications. 

Reports for fractures should indicate the specific bone and type of fracture, as well as laterality. It is also critical to indicate whether a fracture is traumatic or pathologic.

Specificity Affects Payment 

Why should radiologists worry about being so specific when the ordering physician usually knows the side affected and the type of disease or injury, etc.? One main reason is reimbursement.

Effective Oct. 1, 2016, the non-specific breast cancer code C50.919 and 42 other unspecified diagnosis codes are being removed from the diagnostic mammogram national coverage determination (NCD). Breast cancer and other breast clinical indications must be coded to the specific breast at a minimum or the claim will be denied. 

Code M85.80 for unspecified osteopenia has already been removed from the bone density NCD and is being replaced by codes for osteopenia at specific locations. If “osteopenia” is the only diagnosis, the claim will be denied. CMS is revising other NCDs and various MACs are revising local coverage determinations (LCDs) to eliminate payment when a non-specific diagnosis code is provided. Commercial payors are expected to do the same.  

In addition to payment, more specific diagnoses will give radiologists more data to use for better payment. More data is becoming more important as we move ever closer to value-based payment systems. 

Teamwork Required

While radiologists do not necessarily need to learn the ICD-10-CM codes, they must be cognizant of the requirements for diagnosis coding. Documentation should conform to the standards of official ICD-10-CM coding rules.  

For example, one common documentation mistake is the use of “history of” and “follow-up.” “History of” is often used to indicate the current clinical indication. However, in ICD-10-CM, “history of” means that the patient has a past medical condition that no longer exists and is not receiving any treatment, but has the potential for recurrence. “Follow-up” goes along with “history of” because follow-up codes indicate continued surveillance following a completed treatment of a condition, not follow-up during treatment.   

Radiologists, radiology practices, and radiology departments must work together and with the ordering physicians to obtain the most specific clinical indications possible. Radiologists must document that clinical indication in the interpretation report so that coders can choose the most appropriate and specific codes available. Coders must be able to query the radiologist or ordering physician for clarification, and radiologists should understand that the coder is trying to get the best diagnosis so a claim will not be denied. 

While the number and specificity of diagnosis codes can appear daunting, if everyone works together, not only will there be fewer claim denials, but better quality data will be accumulated to help improve the quality of patient care.


Donna Richmond, BA, RCC, CIRCC, CPC

Donna is a Senior Healthcare Consultant at Panacea Healthcare Solutions. She has worked for more than 25 years in medical billing, coding and compliance, with a primary focus on radiology, including nuclear medicine. She has published articles in several newsletters and magazines and is a frequent presenter of radiology webcasts and seminars.

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