CODING Q&A

The Big ICD-10 Update is Here

SUZANNE L. CORCORAN, COE

ICD-10-CM diagnosis codes have been updated for the first time in five years, effective October 1. There are 1,974 new codes, 311 deleted codes, and 425 revised codes. In addition to code changes, some tabular instructions were revised to provide clarity. Here’s what retina physicians should know.

Q. What type of changes can we expect when coding for AMD?

A. When originally published, dry AMD — regardless of which eye — was coded as H35.31. Wet AMD was coded as H35.32, again without specifying which eye. The update effective October 1 adds laterality and also adds “staging.” The eye will be indicated by the sixth digit in the ICD-10 code, and the stage of AMD will be the seventh digit.

Q. How are the stage codes described for dry AMD?

A. There are five stages, including unspecified, listed for dry AMD. They are:

0 – stage unspecified

1 – early dry stage

2 – intermediate dry stage

3 – advanced atrophic without subfoveal involvement advanced dry stage

4 – advanced atrophic with subfoveal involvement

The seventh character, the stage, of the ICD-10 code for dry AMD will be 0-4.

For example: H35.3112, non-exudative AMD, right eye, intermediate stage. The sixth digit “1” indicates the right eye, and the seventh digit “2” represents intermediate stage.

Q. Does the same approach apply to wet AMD?

A. Yes, but with some variation. The sixth digit will be for laterality but only four stages, including one unspecified, exist for wet AMD. They are:

0 – stage unspecified

1 – with active choroidal neovascularization

2 – with inactive choroidal neovascularization with involuted or regressed neovascularization

3 – with inactive scar

The seventh character, the stage, of the ICD-10 code for wet AMD will be 0-3.

For example: H35.3221 describes a patient with exudative AMD, with active CNV in the left eye. The sixth digit “2” indicates the left eye, and the seventh digit “1” indicates active CNV stage.

Q. Is there a definition of the various stages of AMD?

A. There are several classifications of AMD in various publications. The American Academy of Ophthalmology uses the Age-Related Eye Disease Study (AREDS) to classify AMD. The Academy published it in their Preferred Practice Patterns document on Age-Related Macular Degeneration.¹

• No AMD (AREDS category 1) represented the control group; it is characterized by no or few small drusen (<63 µm in diameter).

• Early AMD (AREDS category 2) is characterized by a combination of multiple small drusen, few intermediate drusen (63 to 124 µm in diameter), or mild RPE abnormalities.

• Intermediate AMD (AREDS category 3) is characterized by any of the following features:

• Numerous intermediate drusen

• At least one large druse (125 µm or larger in diameter)

• Geographic atrophy (a sharply demarcated, usually round or oval, area of atrophy of the RPE not involving the center of the fovea)

• Advanced AMD (AREDS category 4) is characterized by one or more of the following (in the absence of other causes) in one eye:

• Geographic atrophy of the RPE involving the foveal center

• Neovascular maculopathy that includes the following:

• Choroidal neovascularization defined as pathologic angiogenesis originating from the choroidal vasculature that extends through a defect in Bruch’s membrane

• Serous and/or hemorhagic detachment of the neuro-sensory retina or RPE; retinal hard exudates (a secondary phenomenon resulting from chronic intravascular leakage)

• Subretinal and sub-RPE fibrovascular proliferation

• Disciform scar (sub-retinal fibrosis)

Q. Are there changes to diabetes coding?

A. Approximately 260 new diabetic combination codes become effective on October 1. Some examples:

• Diabetic retinopathy codes added laterality, changing them from six to seven digits

◦ E11.3293 (Type II DM, mild NPDR, no DME, bilateral)

• New diabetic codes including other retinal disease and resolved disease

◦ E11.3531 (Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye)

◦ E11.3552 (Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye)

◦ E10.37x3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

Q. What additional changes to the retinal disease section of ICD-10 will we find?

A. A seventh character further describing the patient’s disease was added to the retinal vascular occlusion codes. The sixth digit continues to indicate which eye.

H34.81 Central retinal vein occlusion

One of the following seven characters is to be assigned to codes in subcategory H34.81 to designate the severity of the occlusion:

0 – with macular edema

1 – with retinal neovascularization

2 – stable

Old central retinal vein occlusion

H34.83 Tributary (branch retinal vein occlusion

One of the following seventh characters is to be assigned to codes in subcategory H34.83 to designate the severity of the occlusion:

0 – with macular edema

1 – with retinal neovascularization

2 – stable

Old tributary (branch) retinal vein occlusion

Q. What changes were made to the instructions providing more clarity?

A. Clarification to the instructions regarding etiology/manifestation note that an underlying condition should only be coded when it is applicable. There has been confusion about how to code some diagnoses when there was no underlying condition.

Confusion about applying laterality (which eye) has been resolved. Basically, it says to use the bilateral code when both eyes have the same condition, even if only one eye is being treated. We believe this is appropriate for exams and most tests, but likely not for surgery. For example, if a patient has bilateral wet AMD, you should continue to code right or left eye for the injection, unless you are treating both eyes.

A point of confusion from the outset of ICD-10 has been the “Excludes 1” and “Excludes 2” designations. Some conditions with an “Excludes 1” notation could also have a second condition, but the “Excludes 1” note did not permit using both codes. In the updated manual, some “Excludes 1” notes were changed to “Excludes 2” notes, allowing for some conditions previously disallowed by the “Excludes 1” note to now be coded together. For example, ICD-10 code H42, glaucoma in diseases classified elsewhere, could not be coded along with diabetes; the update removes that exclusion.

Q. Will CMS continue to allow nonspecific codes as long as we are in the right “family” of codes?

A. Very unlikely. CMS stated in July 2015 that it would not deny or audit claims just for specificity for a year after implementation of ICD-10, as long as the billed code is from the appropriate “family of codes.” Most Medicare contractors accepted and paid claims with unspecified codes as long as the code was from the appropriate family of codes. The “honeymoon period” ends as of September 30, 2016.

Q. What else should we think about with the implementation of these ICD-10 changes?

A. There are several things to monitor:

• Update your EMR and practice management system with the new codes

• Remember that some of the new codes replace others, which will no longer be accepted on claims

• Train physicians and staff regarding the new codes

• Monitor coverage guidelines and Local Coverage Determinations by payers, and be prepared to contact them if new codes are not added to coverage policies. RP

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