The Centers for Medicare and Medicaid Services is launching a series of new ICD-10 guidance documents for physician practices of multiple specialties, serving as virtual cheat sheets for selecting the appropriate coding.
The guidance, starting with family practice, walks through all the typical clinical scenarios in a wide range of services that a family physician typically sees, and gives the appropriate code for each type of scenario in each type of category.
The guidance for family practice alone is 31 pages in length, giving common codes for specific services across a dozen types of treatment, and giving the specific codes for specific services within each treatment type. For instance, it gives the appropriate code for 12 specific types of abdominal pain.
Other treatment categories with the appropriate code given for specific types of conditions cover acute respiratory infections, back/neck pain, chest pain, other forms of heart disease, diabetes mellitus without complications Type 2, general medical examination, headache, hypertension, pain in joint, pain in limb, and urinary tract infection/cystitis.
CMS in its guidance also offers clinical documentation tips covering hypertension, asthma, underdosing, abdominal pain or tenderness, and diabetes/hypoglycemia/hyperglycemia. For instance, when documenting why a physician is underdosing a patient, one of three ICD-10 codes can be selected:
Z91.120: Patient’s intentional underdosing of medication regimen due to financial hardship;
T36.4x6A: Underdosing of tetracyclines, initial encounter; or
T45.526D: Underdosing of antithrombotic drugs, subsequent encounter.
The guidance, which also gives extensive information on improving specificity in documentation, is available here.
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