ICD 10 Coding Consistency – Message from APTA
Friday, February 12, 2016
Posted by: Bibiana Braun
When our profession moved from ICD-9-CM to ICD-10-CM, there was inconsistency between APTA, the American Hospital Association (AHA), and the American Health Information Management Association (AHIMA) in guidance on how to select the first-listed diagnosis for patients receiving outpatient physical therapy services. For clarification, APTA contacted the ICD-10 Cooperating Parties, which include AHA, AHIMA, CMS, and the Centers for Disease Control and Prevention.
The Cooperating Parties agree that with the transition to ICD-10, it is important that all health care providers code consistently.
The Health Insurance Portability and Accountability Act (HIPAA) requires providers to assign ICD-10-CM diagnosis codes according to the ICD-10-CM Official Guidelines for Coding and Reporting. The guidelines state:
"...when a definitive diagnosis has been established for that encounter, the established diagnosis should be coded. In this case, those signs or symptoms that are integral to the established diagnosis should not be coded. Any conditions, including signs and symptoms, that are not routinely associated with the definitive diagnosis should be assigned as additional codes."
In addition, the guidelines state:
“Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider.”
APTA recognizes that payers have not been consistent with instructions on the first-listed diagnosis, and physical therapists may have been coding a treatment/functional diagnosis code first even when a definitive diagnosis has been confirmed. Going forward with ICD-10, APTA believes the first-listed diagnosis should be consistent with the ICD-10 Coordinating Parties, payers, and other organizations, and the association’s guidance will reflect this practice.
APTA is concerned that there may be situations during this transition that would lead to payers to delay or deny claims. If you are aware of any member who has followed the ICD-10-CM Official Guidelines for Coding and Reporting, yet had a claim delayed or denied, please ask them to complete the Online Complaint Form on APTA’s website so the association can help resolve the issue.
APTA is updating our website resources on ICD-10 (www.apta.org/ICD10) to reflect this important information, and we expect it to be available before CSM. In addition, APTA will include information about this in the February 26th addition of PT in Focus.