RheumWATCH Archives

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Read the RheumWATCH archives on topics such as rheumatology advocacy, policy updates, insurance advocacy, and practice management.

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Unspecified Codes and ICD-10; ACR Legislative Fly-in and Hill Briefing Recaps

Use of Unspecified Codes in ICD-10: What You Need to Know

The ACR Practice Management and Coding department will periodically update the membership on the new ICD-10 coding guidelines and conventions to assist practices with accurate billing. Our top question during the first week of implementation of ICD-10 was on the use of unspecified codes.

Now that ICD-10 has been implemented, it will be crucial to monitor your practice closely for the next 30–60 days to ensure coding accuracy, tweak processes to locate diagnosis codes efficiently, and verify that claims are transmitted successfully and reimbursement has not been affected.

While we are all settling into the daily routine of caring for patients and billing out the charges, we will encounter codes that are unclear and do not even identify the patient’s condition.

In both ICD-9 and ICD-10, signs/symptoms and unspecified codes are acceptable, and may even be necessary in some cases, as there may not be enough information to describe the patient’s condition or no other code is available to use. While you should report specific diagnosis codes when they are supported by the available documentation and clinical knowledge of the patient’s health condition, in some instances, signs/symptoms or unspecified codes are the best choice to accurately reflect the healthcare encounter.

There are legitimate uses of a less specific or unspecified code, depending on the situation. The ultimate question comes down to, “Does the code reflect as accurately and precisely as possible the patient’s condition or the services performed to maintain or improve that condition for that encounter?”

For example:
M32.9 – Systemic Lupus Erythematosus, unspecified

  • SLE NOS
  • Systemic lupus erythematosus NOS
  • Systemic lupus erythematosus without organ involvement
    • It is appropriate to use the unspecified code M32.9 for lupus, as there is no other code in the category for just lupus without involvement.

M32.10 – Systemic Lupus Erythematosus, organ or system involvement unspecified

  • Considering the level of information available to the physician, the findings at the time are nonspecific and the patient may need further work-up. This code would be more appropriate than a code that guesses at the fact that the patient may have a specific organ or system involvement that has not been confirmed.

The use of any other code within this category would be based on the fact that the patient has some organ involvement that is confirmed and documented (codes M32.11-M32.15 are specific to organ involvement). Additionally, M32.19 (Other organ or system involvement in systemic lupus erythematosus) should be used if the patient has involvement in an organ or system not listed within the category, and M32.8 (Other forms of systemic lupus erythematosus) refers to the provider not knowing the nature or specifics of the condition.

BUT, for codes that provide or require specificity for laterality (left, right, or unspecified side), every provider should be able to document right vs. left as well as the anatomical site.

M25.46 – Effusion, knee

  • M25.461 – Effusion, right knee
  • M25.462 – Effusion, left knee
    • The clinician should be able to code the site/side and in this case, whether it is the left or the right.

M25.469 – Effusion, unspecified knee

  • There is little justification for the use of this code, since the specific knee/anatomical site should be known to the clinician treating the patient.

We do not know how payers will handle these unspecified codes, but practices need to be prepared to respond as they receive feedback from the payers. An additional complication is that all payers will not handle these codes the same way at the same time. Therefore, it is important to be acutely aware of the nuances around appropriate use of unspecified codes.

Keep in mind that approximate conversions between ICD-9 and ICD-10 codes may require clinical interpretation in order to determine the most appropriate conversion code(s) for your specific coding situation. We recommend that practices purchase an ICD-10 book for their practice to help with understanding the coding guidelines and conventions until we are all more experienced with the code set. The ICD-10 book is the official manual for the code set, and most EMR systems do not have the coding rules and/or conventions built in to guide the providers on the ins and outs of coding.

The ACR’s certified coders are here to assist with all your coding needs. Send specific coding questions to practice@rheumatology.org, or directly contact Melesia Tillman at 404-633-3777, ext. 820 (mtillman@rheumatology.org) or Antanya Chung at 404-633-3777, ext. 818 (achung@rheumatology.org).

Please also visit the ICD-10 page for coding updates and information on future training sessions.

Meaningful Use Exemption Available If You Switched EHR Vendors

CMS recently clarified that physicians who switch electronic health record (EHR) vendors now can qualify for a hardship exemption to avoid penalties under the meaningful use program. The ACR was among the groups that advocated for this hardship exemption to be made available.

Many physicians who are not satisfied with their EHR systems are considering purchasing and migrating to alternative products. Switching vendors is an expensive and time-consuming process, and physicians who opt to switch vendors risk failing to meet all the requirements necessary to successfully attest for the meaningful use program.

In a new frequently asked questions document, CMS clarifies that physicians who have switched EHR vendors during the meaningful use program year can apply for an “Extreme and/or Uncontrollable Circumstances Hardship Exception.” If approved, those physicians will be exempt from meaningful use penalties for the year they switch technology. However, CMS is not clear about whether this exemption covers physicians who switch platforms or upgrade technology while staying with the same vendor—which also can be disruptive. For more information on hardship exemptions, visit CMS’ hardship information page.

CMS also clarified that a decertified EHR may still be used to meet meaningful use requirements if the reporting period ended before decertification occurred. If the reporting period ends after a product is decertified, CMS says physicians may apply for a hardship exemption. For further information on decertified EHRs, visit CMS’ FAQ page.

If you need assistance with the meaningful use program and/or need help attesting or applying for hardship exemptions, contact ACR staff at mgueye@rheumatology.org.

2015 ACR Advocates for Arthritis Fly-In Recap; Hill Briefing Held with AF and NPF

Over 100 rheumatologists, health professionals, and patients gathered in our nation’s capital on Oct. 5–6 to take part in this annual legislative event, where participants learned more about the federal legislative process and urged their members of Congress to support legislation that impacts rheumatology and the health of millions of patients.

Hill Briefing
During the fly-in, the ACR, the Arthritis Foundation, and the National Psoriasis Foundation—in conjunction with the Congressional Arthritis Caucus—joined together for a briefing on access challenges and policy solutions. The briefing, “America’s Pediatric Arthritis Specialist Shortage: What It Means for Kids, Cost and Care,” can be viewed on the ACR’s Advocates for Arthritis page and YouTube channel.

New Legislative Action Center
Visit the ACR’s new Legislative Action Center to send a personalized message to your lawmakers asking them to give patients access to treatments, to support funding for biomedical research, and to prevent insurer practices interfering with treatment and care.

Message from the Government Affairs Committee

The American College of Rheumatology has championed a new effort to educate and engage young rheumatologists in health policy and patient advocacy. On Oct. 5–6, in conjunction with the annual fly-in, a new program known as Advocacy 101 brought 13 fellows-in-training and two program directors from nine states to Washington, D.C., to learn about advocacy and health policy. Participants also joined rheumatologists and patient advocates from across the country for training and a day of visits with legislators and staff on Capitol Hill.

Rheumatologists face many challenges associated with our rapidly changing U.S. healthcare system. The Government Affairs Committee (GAC) has been leading the charge for legislative action to address these challenges, including increasing access to providers, access to treatments, reducing practice burdens, and funding for scientific research. The GAC recognized the need for increased engagement among young rheumatologists and as a result established Advocacy 101, a health policy and advocacy training program designed specifically for rheumatology fellows and program directors.

A recent survey of rheumatology fellows in U.S. training programs revealed that only a small proportion are actively participating in health policy and advocacy efforts, despite a strong desire to do so. Even fewer have had formal training in health policy or are aware of educational opportunities within their current training program. Fellows indicated an interest in becoming involved, but cited their lack of knowledge on the issues and on how to participate as their biggest barriers.

During Advocacy 101, fellows and program directors spent a full day learning about health policy and advocacy issues. Topics included how a bill (for example, H.R. 1600, the Patients’ Access to Treatment Act) becomes a law, the CMS and MACRA structure, and private insurance advocacy. Participants heard from ACR president-elect Dr. Joan Von Feldt about her experience as an advocate for the ACR; from former Senator Tim Hutchinson, now a lobbyist for the ACR, about how to build relationships with elected officials; and from a former health legislative assistant about how to be an effective advocate on Capitol Hill. Fellows also discussed future outreach programs to teach and engage their co-fellows about advocacy-related issues.During Advocacy 101, fellows and program directors spent a full day learning about health policy and advocacy issues.

Advocacy 101 participants then joined the ACR advocates for a training day and accompanied groups of rheumatologists and patients from their home states for visits with legislators and staff on Capitol Hill.

The ACR recognizes engagement in health policy and advocacy efforts as critical to the continued ability to recruit trainees into the field, support education and research, and advance clinical practice. Advocacy 101 is the first formal program designed to educate and engage rheumatology fellows and their program directors in health policy and advocacy endeavors.

Participants expressed great enthusiasm for learning more about the issues that affect practice and patient care, as well as a desire to share what they learned through Advocacy 101 with their colleagues.

The Government Affairs Committee looks forward to building an exciting future by encouraging and including young members in advocacy efforts. We aim to expand Advocacy 101 into a continuing effort to facilitate ongoing education and engagement amongst members. With the younger generation of rheumatologists understanding the challenges we face and harboring a strong will to advocate for their patients, we can make great strides in Advancing Rheumatology! and the needs of our patients.

Sarah Doaty, MDSarah Doaty, MD
Fellows Subcommittee Representative, Government Affairs Committee

 

 

Elizabeth Solow, MDElizabeth Solow, MD
Member, Government Affairs Committee