ICD-10 in Action: Common reporting errors

February 12, 2018

This Independence series, ICD-10 in Action, features articles to recap some of the ICD-10 diagnosis code changes, introduce new coding scenarios, and communicate updates to ICD-10 coding conventions.

The ICD-10-CM Manual contains official guidelines for coding and reporting. There are coding conventions, general coding guidelines, and chapter-specific guidelines, as described below, which must be followed to classify and assign the most appropriate ICD-10 code when submitting a claim. Understanding these guidelines and conventions is key to reaching the most appropriate code assignment.

  • Conventions. A set of rules for use of the classification independent of the general or chapter-specific guidelines. Coding conventions and instructions of the classification take precedence over guidelines. (e.g., Code First).
  • General guidelines. A set of rules and sequencing instructions for using the Tabular List and Alphabetic Index. These guidelines provide rules such as how to locate a code and obtain level of detail.
  • Chapter-specific guidelines. A set of rules for specific diagnoses and conditions in a particular classification.
As with ICD-9, adherence to these guidelines is required under the Health Insurance Portability and Accountability Act (HIPAA).

Coding convention ? Common reporting errors

Mistakes and accidents are part of life and, at times, unavoidable. However, when it comes to errors in clinical documentation and reporting, mistakes and accidents can be costly and detrimental for both providers and patients.

Here is a hypothetical scenario:

A 35-year-old female went to see her endocrinologist for treatment and management of Polycystic Ovarian Syndrome (PCOS). The endocrinologist performed a routine treatment plan, which includes monitoring lab results as well as refilling or adjusting prescriptions as necessary. The patient said she was experiencing gastrointestinal side effects from the prescribed drug Glucophage®. The physician recommended she try Glucophage® XR (extended release) instead, as this formulation may reduce or eliminate the side effects she experienced. Six months later, the patient started receiving calls from a health coach at her insurance company as a courtesy to help her manage her ?diabetes.? The patient is confused because she does not have diabetes.

This health coach call occurred because someone reviewing the patient's clinical documentation saw the patient was taking Glucophage®, a common diabetic medication, assumed she had diabetes, and used the incorrect coding convention to document the "diagnosis." Because the wrong coding convention was used, the wrong condition was assigned to the patient. The patient is taking Glucophage® XR for insulin resistance, which is a common condition of PCOS.

Thankfully there were no medical or cost impacts to the patient. However, there were many letters mailed and phone calls made to trace the source and correct the diagnosis. There could have been a great impact to the patient, especially if the medication was not covered for the diagnosis of PCOS.

Even though the above scenario may not be common, there are some common reporting errors that can cause delays, denials, or rejected claims. To avoid these errors, it is important to make sure the documentation is clear and the coding is accurate for the condition and services performed.

When providing code assignment, the diagnosis code that describes the patient's diagnosis, symptom, condition, or complaint must be reported.

Here are some examples of common reporting errors:

  • Incorrect code assignment. The wrong code is used for the patient's condition. As in the scenario above, the correct code assignment is PCOS and not diabetes.
    • Incorrect:
      E11.8 Type 2 diabetes mellitus with unspecified complications
    • Correct:
      E28.2 Polycystic ovarian syndrome
  • Invalid or truncated codes. These are codes that are not taken to the highest level of specificity.
    • Incorrect:
      E11.61 Type 2 diabetes mellitus with diabetic arthropathy
    • Correct:
      E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy
  • Laterality conflict. When reporting a diagnosis code that specifies laterality (right, left), all other code sets (e.g., modifiers) must match.
    • Incorrect:
      M60.211 Foreign body granuloma of soft tissue, not elsewhere classified, right shoulder
      23330 Removal of foreign body, shoulder; subcutaneousLT ? Left side (used to identify procedures performed on the left side of the body)
    • Correct:
      M60.211 Foreign body granuloma of soft tissue, not elsewhere classified, right shoulder
      23330 Removal of foreign body, shoulder; subcutaneousRT ? Right side (used to identify procedures performed on the right side of the body)
  • Incorrect diagnosis linking. The diagnosis code must point to the procedure code performed for that condition. This demonstrates the appropriateness and medical necessity of the service performed.
    • Incorrect:
      Z00.00 Encounter for general adult medical examination without abnormal findingsLinked to69209 Removal impacted cerumen using irrigation/lavage, unilateral
      99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
    • Correct:
      Z00.00 Encounter for general adult medical examination without abnormal findingsLinked to99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
      H61.23 Impacted cerumen, bilateral69209 Removal impacted cerumen using irrigation/lavage, unilateral
  • Inappropriate use of unspecified codes. It is not acceptable to report the "unspecified" code when clinical documentation is known or available. The unspecified code is appropriate only if there isn't sufficient documentation to assign a more specific code.
    • Incorrect:
      R10.9 Unspecified abdominal pain
    • Correct:
      R10.31 Right lower quadrant pain

    Stay tuned

    Look for a new series of information regarding ICD-10 later this year in Partners in Health UpdateSM.