ICD-10 codes aren't oppressive after all

Alexander Miller, M.D., a dermatologist in Yorba Linda, Calif., has a simple message for colleagues grappling with the new ICD-10 codes: Don't panic!

"It's just a matter of restructuring one's thinking," Dr. Miller tells Dermatology Times. "It was no problem for us to handle these codes," he says, even in his office that continues to rely on paper health records.

But there are still a number of changes in the codes that affect dermatologists who are seeking reimbursement. And dermatologists will need to put up with the complexities in order to be reimbursed properly.

Dr. Miller spoke about the revisions in an interview with Dermatology Times and at the 2016 CalDerm Symposium, a continuing education seminar offered by the California Society of Dermatology & Dermatologic Surgery.

According to Dr. Miller, these are some lessons that dermatologists and their staffs should remember about the codes, known officially as the International Statistical Classification of Diseases and Related Health Problems 10th Revision, which went into effect in October 2015:

Next: Mind the specifics of the codes

Mind the specifics of the codes

"There is greater specificity" in the ICD-10 codes, Dr. Miller says, "but it's by no means overwhelming."

Even so, dermatologists and office staff will have to focus carefully when it comes to many of the 68,000 ICD-10 codes.

Cysts, for example, can be coded as epidermal cyst (L72.0), pilar cyst (L72.11), trichodermal cyst/trichilemmal (proliferating) cyst (L72.12),

steatocystoma multiplex (L72.2), sebaceous cyst (solitary steatocyst) (L72.3) and other follicular cysts of the skin and subcutaneous tissue (L72.8).

Eyelid cysts, meanwhile, have a list of codes of their own: Cysts of right upper eyelid (H02.821), cysts of right lower eyelid (H02.822), cysts of left upper eyelid (H02.824) and cysts of left lower eyelid (H02.825).

And, if a patient has a symptomatic nevus, the primary code (D22) isn't enough. It must be more specific, such as D22.0 (melanocytic nevi of lip) or D22.1 (melanocytic nevi of eyelid, including canthus; this code is further divided into codes for specific eyelids), and so on. Secondary codes like L29.8 (other pruritus) and R20.2 (paresthesia of skin) may also be appropriate.

Next: Focus on what you know

Focus on what you know at the time

In some cases, it's important to remember that codes are based on what a physician knows at the moment, not the ultimate diagnosis.

For example, the code for TB skin test is not A18.14 (tuberculosis of skin). Instead, Dr. Miller recommends using the patient’s condition (e.g., psoriasis, L40.-) and Z11.1: encounter for screening for respiratory TB (screening for TB: Mantoux, skin test).

Also, keep an eye out for coding quirks. Daylight photodynamic therapy -- aminolevulinic acid is applied in office and the patient sits in shade for 2-3 hours -- does qualify under HCPCS code J7308 (aminolevulinic acid, 20%) but not CPT 96567 (light exposure done in sunlight, outside your facility). Still, you may bill an appropriate patient evaluation and monitoring code (CPT 999201-99215).

Next: Be aware of new CPT codes

Be aware of new CPT codes

Current Procedural Terminology (CPT) codes refer to procedures and services. Several new ones have been created for Reflectance Confocal Microscopy from 96931-96936, Dr. Miller says.

He cautions that the codes can be used a free-standing device that produces stacked mosaic images but not for a hand-held confocal device.

New Category III CPT codes are also available. These are temporary numerical codes with a T at the end, designated for emerging technology, services and procedures.

Insurers may or may not provide coverage, Dr. Miller says. Even if they're not covered, however, their use could prompt their conversion to permanent Category I codes that are more likely to gain reimbursement.

Specifically, Dr. Miller says derms should be aware that the 0182T code for brachytherapy code has been removed. Instead, he says, use CPT code 0394T (High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed).

Also, procedures with the MelaFind device can be coded as CPT 0400T (multi-spectral digital skin lesion analysis for detection of melanomas and high risk melanocytic atypia, one to five lesions) or CPT 0401T for six or more lesions.

For assistance with ICD-10 codes, Dr. Miller advises derms and their staffs to turn to the online coding services provided by the American Academy of Dermatology and various online databases.

And he suggests that ICD-10 sections on "Symptoms, Signs and Abnormal Clinical and Laboratory Findings" and "Injury, Poisoning and Certain Other Consequences of External Causes" can provide some good light reading. These sections are home to unique codes like V95.40 (unspecified spacecraft accident injuring occupant), X52 (prolonged stay in weightless environment) and S30.867A (insect bite, nonvenomous, of anus, initial encounter).

Keep in mind that "initial encounter" refers to the first time a patient seeks a physician about a condition, not the first time he or she, say, encounters an insect and is non-venomously bitten in the anus. In certain cases, such as poisonings and injuries, the ICD-10 system requires codes that track the sequence of visits by a patient, such as "initial encounter" and "subsequent encounter."

As always, mind the coding. Otherwise, you and your patient -- maybe even the already unfortunate victim of an S30.867A incident -- will risk a denied claim.

Dr. Miller reports no relevant conflicts of interest.