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Last year, urgent cares stretched to understand and implement big changes to ICD-10-CM code guidelines, changing the focus to medical decision making (MDM). This year, the guidance from CMS isn’t nearly as daunting, but it’s definitely worth noting to make sure your team is up to speed.

In this month’s “3 Things to Know About RCM,” we’ll share what’s ahead for ICD-10-CM coding, take a look at how clinicians have navigated the 2021 changes, and explore what’s coming with additional COVID-19 vaccinations.

ICD-10 Changes for 2022

As we head into the fall, it’s time to start thinking about the annual update to ICD-10-CM. Every year on October 1, the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics release an updated ICD-10-CM Official Guidelines as well as changes to the code set. This year there are 159 new codes, 32 deleted codes, and 20 revised codes – a total of 72,748 codes to choose from.

Code U09.9 (Post COVID-19 condition, unspecified) is the only COVID-19 code added for this update. This code is to be used for sequela of COVID-19 or associated symptoms/conditions following a previous infection. It should not be used for current infections. First code the current symptoms/conditions then add code U09.9 as a secondary diagnosis.

Three common diagnoses for urgent care are cough (R05), low back pain (M54.5), and polyuria (R35.8). Starting 10/01/2021, you will need to add a digit for increased specificity.

Cough:

  • Acute cough (R05.1)
  • Subacute cough (R05.2)
  • Chronic cough (R05.3)
  • Cough syncope (R05.4)
  • Other specified cough (R05.8)
  • Cough, unspecified (R05.9)

Low back pain:

  • Low back pain, unspecified (M54.50)
  • Vertebrogenic low back pain (M54.51)
  • Other low back pain (M54.59)

Polyuria:

  • Nocturnal polyuria (R35.81)
  • Other polyuria (R35.89)

Social determinants of health now may have an impact on the level of risk with the implementation of the 2021 E/M guidelines. There are codes to report these circumstances and more detail is being added. These would be reported as secondary diagnoses.

  • Less than a high school diploma (Z55.5)
  • Inadequate drinking-water supply (Z58.6)
  • Homelessness unspecified (Z59.00)
  • Sheltered homelessness (Z59.01)
  • Unsheltered homelessness (Z59.02)
  • Food insecurity (Z59.41)
  • Other specified lack of adequate food (Z59.48)
  • Housing instability, housed, with risk of homelessness (Z59.811)
  • Housing instability, housed, homelessness in past 12 months (Z59.812)
  • Housing instability, housed unspecified (Z59.819)
  • Other problems related to housing and economic circumstances (Z59.89)

Other new diagnoses include:

  • Depression, unspecified (F32.A)
  • Irritant contact dermatitis (L24.A0 – L24.B3)
  • Nonsuicidal self-harm (R45.88)
  • Personal history of self-harm (Z91.51)
  • Personal history of nonsuicidal self-harm (Z91.52)
  • Feeding difficulties, unspecified (R63.30)
  • Pediatric feeding disorder, acute (R63.31)
  • Pediatric feeding disorder, chronic (R63.32)
  • Other feeding difficulties (R63.39)
  • Abnormal findings of blood amino-acid level (R79.83)
  • Encounter for immunization safety counseling (Z71.85)

Finally, there is an entire section for conditions caused by use of cannabis or synthetic cannabinoids. The codes previously described as cannabis (derivatives) were deleted.

Poisoning:

  • Cannabis (T40.711A – T40.714S)
  • Synthetic cannabinoids (T40.721A – T40.724S)

Adverse effect:

  • Cannabis (T40.715A – T40.715S)
  • Synthetic cannabinoids (T40.725A – T40.725A)

Underdosing:

  • Cannabis (T40.716A – T40.716S)
  • Synthetic cannabinoids (T40)

These ICD-10-CM codes will help to make your MDM case on claims. Be sure all your staff is up to date on these new guidelines that go into effect on October 1.

Prepare to Comply with Balance Billing Changes for 2022

In July, The US Department of Health and Human Services (HHS), Labor, and Treasury, and the Department of Personnel Management issued “Requirements Related to Surprise Billing; Part 1, an interim final rule to restrict excessive out-of-pocket costs to consumers from surprise billing and balance billing.

According to an agency press release, “Surprise billing happens when people unknowingly get care from providers that are outside of their health plan’s network and can happen for both emergency and non-emergency care. Balance billing, when a provider charges a patient the remainder of what their insurance does not pay, is currently prohibited in both Medicare and Medicaid. This rule will extend similar protections to Americans insured through employer-sponsored and commercial health plans.”

The interim final rule says that nonemergency services provided by out-of-network providers must be treated like in-network services, unless the insured individual is provided notice and gives consent. This includes equipment and devices, as well as services like telemedicine, imaging, and laboratory, whether or not the provider furnishing the services is present at the facility.

Although the No Surprises Act and this interim final rule involve multiple federal agencies, there will be one central system for patients to lodge complaints with providers who violate the new rules. Although the details have not yet been finalized, here’s what you can do now to prepare:

  1. Be aware of how you are contracting with payers
  2. Payers may take this as an opportunity to make changes to current agreements or renegotiate payment rates
  3. Evaluate carefully whether you want to be in network or out of network with individual payers
  4. Besides assessing your agreements and payment rates with individual payers, you should start preparing how you’re going to communicate with patients
  5. Make sure that your website includes surprise billing disclosures by Jan. 1, 2022. You should prepare your model notice and disclosure forms before you need to start deploying them, by the beginning of next year.

Read the final rule here.

How coders have fared with 2021 updates

No one knew what to expect when the American Medical Association (AMA) decided that CPT® 2021 would have completely different descriptors for the office/outpatient evaluation and management (E/M) codes.

Halfway through 2021, coding experts have a clearer understanding of how the 2021 changes have affected coders. We reviewed comments from experts, and here are the highlights:

  • In general, coders have been quicker to embrace the guidelines than providers
  • It’s still relatively new, and not yet intuitive. Changing habits is difficult
  • There is still a learning curve for providers around documenting their thought process
  • Confusion exists around when to apply new codes. These changes apply only to E/M in the outpatient and office settings — and not to inpatient, home care or nursing home E/M
  • The new codes positively affect the coordination amongst various providers, who are no longer checking the right boxes for coding, but really documenting what they do with patients
  • New changes will likely be revised – so be ready

Coding for the third COVID-19 Dose

The Food and Drug Administration (FDA) approved a third dose of both the Pfizer and Moderna COVID-19 vaccine for certain moderate or severe immunocompromised individuals to be administered 28 days after the initial two-dose series. The same product should be used for all three doses.

The American Medical Association (AMA) added a CPT code 0003A for the third dose of the Pfizer vaccine and 0013A for the third dose of the Moderna vaccine. The allowable for this administration of the vaccine is the same as previous doses.

Interested in more urgent care tips, best practices, and industry updates? Check out our July and August installments.

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