American College of Physicians: Internal Medicine — Doctors for Adults ®


'Modest' ICD-9 updates must go into effect on Oct. 1

From the October ACP Observer, copyright 2007 by the American College of Physicians.

By Brian Whitman

Practice RxThe CDC's National Center for Health Statistics announces changes to the ICD-9-CM every summer, and the new codes go into effect on Oct. 1. In the past, the Centers for Medicare and Medicaid Services (CMS) allowed physicians to use both the old and the new diagnosis codes for the first three months of implementation, but that has not been the case for a number of years. Physicians must now discontinue use of deleted codes and begin use of new codes every October. Many private insurers follow these same rules, so it is best to update your ICD-9 coding material this month.

Q: Will any changes made this year affect internists?

A: The changes this year were relatively modest, but some changes will affect the diagnosis codes used by internists. The following changes took place Oct. 1. The first sections are codes that were deleted in favor of more specific five-digit ICD-9-CM codes.

787.2 Dysphagia

Replaced with
787.20 Dysphagia, unspecified
787.21 Dysphagia, oral phase
787.22 Dysphagia, oropharyngeal phase
787.23 Dysphagia, pharyngeal phase
787.24 Dysphagia, pharyngoesophageal phase
787.29 Other dysphagia

789.5 Ascites

Replaced with
789.51 Malignant ascites
789.59 Other ascites

255.4 Addison’s disease

Replaced with
255.41 Glucocorticoid deficiency
255.42 Mineralocorticoid deficiency

V17.4 Family history of other cardiovascular disease

Replaced with
V17.41 Family history of sudden cardiac death
V17.49 Family history of other cardiovascular disease

V68.0 Issue of medical certificates

Replaced with
V68.01 Disability examination
V68.09 Other issue of medical certificates

As usual, there has also been a large number of ICD-9 diagnosis codes added. There were 54 codes added describing various lymphomas, primarily in the 200.3x and 200.4x area of the coding system. Limitations on space do not allow for their full inclusion here. There are a number of other additional codes that became effective on Oct. 1. A selection of added codes that may be used by internists includes:

359.21 Myotonic muscular dystrophy
359.22 Myotonia congenital
359.23 Myotonic chondrodystrophy
359.24 Drug-induced myotonia
359.29 Other specified myotonic disorder
414.2 Chronic total occlusion of coronary artery
415.12 Septic pulmonary embolism
440.4 Chronic total occlusion of artery of the extremities
488 Influenza due to identified avian influenza virus
V12.53 Personal history of sudden cardiac arrest

A full list of the code additions, deletions and revisions is available from CMS.

ACP’s Practice Management Center has updated its Commonly Used ICD-9 reference sheet with the new changes that went into effect on Oct. 1. ACP members can access the card in Microsoft Word and PDF format online. A laminated version is also available by contacting the Practice Management Center.

Q: I had a patient who came in for an annual preventive exam, but I discovered a problem and treated that during the visit. Can I bill for both the preventive service and the problem-oriented service or do I have to just choose one?

A: If you are submitting claims to a payer that strictly follows CPT guidelines, you could submit claims for both a preventive service and another service by appending modifier-25 (significant, separately identifiable evaluation and management service) to the problem-oriented service (e.g. 99213). The payer would then pay for both services in recognition of the two services performed.

Unfortunately, many payers have different policies on this issue. Some private insurers refuse to pay for the second service and will simply deny payment for that code. Other payers have chosen to pay 50% of the contracted fee schedule amount on the second service. United Healthcare announced that this will be their payment policy as of Sept. 15. Other payers follow CPT requirements and pay in full for both codes. The coding for the service would not likely change based on these payment policies, but you may reconsider providing problem-oriented and preventive services at the same visit to a patient if all or even half of your work goes unpaid.

Q: What if this was for a Medicare patient?

A: Medicare does not pay for preventive E&M services, with the exception of the Welcome to Medicare exam. The Welcome to Medicare exam is only available to patients during their first six months of Medicare enrollment and has elements that require the use of a different code from the CPT preventive services codes. Physicians can provide preventive services to patients but Medicare will not pay for most of them.

Because preventive physical exams are never covered services, physicians are not required to have patients sign an Advanced Beneficiary Notice (ABN) in order to charge them for preventive exams (e.g. 99397). However, a physician practice should still ensure that a patient understands that he or she may be financially liable for a service before providing it.

Medicare does not allow physicians to bill Medicare for the problem-oriented visit and charge the patient the full price for the preventive visit. Instead, Medicare allows the physician to bill the patient for the difference between the physician’s established charge for the problem-oriented visit (e.g. 99214) and the preventive visit (e.g. 99397). This is not the difference between the payment or Medicare fee schedule amount for the covered service and the charge for the preventive service, but the difference in charges for both services.

If a physician is performing and charging for both preventive services and problem-oriented services, it is best to make the documentation clear as to what element is preventive and what element is problem-oriented in case an audit ever occurs.

Brian Whitman is Senior Analyst for Regulatory and Insurer Affairs in ACP's Washington office.


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