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Q&A: What you need to know about ICD-10


In this Q&A, Ophthalmology Times talks to Michael Repka, MD, MBA and medical director of government affairs for the American Academy of Ophthalmology how the transition to ICD-10 is affecting ophthalmologists.

Take-home message: In this Q&A, Ophthalmology Times talks to Michael Repka, MD, MBA and medical director of government affairs for the American Academy of Ophthalmology how the transition to ICD-10 is affecting ophthalmologists. 


By Stephanie Skernivitz

ICD-10 officially debuted on Oct. 1, and this marks the 10th revision of the official International Statistical Classification of Diseases and Related Health Problems, a list devised by the World Health Organization. This means that claims for any service provided on or after Oct. 1 will be required to have one or more of the new diagnostic codes.

Within the documentation are more than 68,000 codes for diseases, signs/symptoms, and subclassification of diseases; for comparison, the previous version, ICD-9 (in existence since 1979) contained just 14,000 codes. According to experts, the revised set of codes is designed to help physicians, hospitals, and insurance companies with reimbursements.

Recent news reports indicate that there are concerns within the physician community that if physicians’ offices code incorrectly or third-party payers make mistakes when processing claims, it will inhibit the cash flow of the practice significantly, among other issues.

Michael Repka, MD, MBA, medical director of government affairs for the American Academy of Ophthalmology, who has spoken in recent years on ICD codes and how the changes will impact ophthalmology, recently discussed ICD-10 with Ophthalmology Times. Here’s the abbreviated Q&A with Dr. Repka.

OT: What highlights about ICD-10 would you say are most worthy of mentioning? What would ophthalmologists be most interested in knowing about, relevant to ICD-10?

Dr. Repka: One of the most notable changes is in diabetes coding. Documentation of non-insulin dependent diabetes mellitus (NIDDM) and language such as “controlled” or “uncontrolled” and “juvenile-onset” or “adult-onset” has become obsolete. So before, what was potentially three ICD-9 codes has now become one ICD-10 code. This single diagnosis now lists the type of diabetes, the existence of retinopathy, type and severity, and whether the patient has macular edema.

More generally, the story is all about laterality coding. Many codes require the physician to state right, left, bilateral, or unspecified. In many cases, it will be important to code diseases specific to each eye.

However, not all codes include laterality, so it’s imperative to know when an additional character is required. Leaving off an additional digit or adding one when it does not belong may cause a claim to be delayed or denied.

OT: The new code set enables a significant increase in the specificity of the reporting, allowing more information to be conveyed in a code. How does this impact ophthalmologists?

Dr. Repka: There are quite a few examples where specificity will be important when coding ICD-10. One example is that operative reports will need to be more specific. For example, glaucoma surgeons will need to identify if the glaucoma stage is mild, moderate, or severe.

In terms of cataract surgery, ophthalmologists should be more specific in the type of cataract being removed. There are 70 options for cataracts in ICD-10. Rather than stating “cataracts” as the diagnosis, the chart and reports must reflect the type accurately.

OT: Terminology has been modernized and made consistent throughout the code set. What is the impact on ophthalmologists?

Dr. Repka: There is not a big impact for ophthalmologists per se, as there are few terminology changes in the eye section.

OT: There are now codes that involve a combination of diagnoses and symptoms, so that fewer codes need to be reported to describe a condition fully. Is this a good or bad thing?

Dr. Repka: (There’s) minimal effect in ophthalmology. Most claims still require specific codes for signs and symptoms if the practitioner wants to code both. They are under no compulsion to do that.

OT: Are there other major changes of which ophthalmologists need to be aware?

Dr. Repka: Facing denied claims is the single greatest challenge practices will face after the transition to ICD-10, so it will be important to correct claims promptly to prevent issues with reimbursement. Because it takes payers about two weeks to process an electronic claim, any errors in ICD-10 code selection will have been perpetuated for that period of time. I would monitor all remittance advices and act quickly if there is a denial.

Also, make sure your EHR module is up to date. And keep in mind there will be more new codes in October 2016!

Avoid general equivalence mappings that lead you to unspecified codes.

OT: ICD-10 reflects significant changes in the way health plans reimburse services, and in the way coverage of services is determined. What are the details of this that are most relevant to ophthalmologists?

Dr. Repka: All payers have to update their coverage policies. Assuming this has been done correctly, there should be no problem.

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