ICD-10 and Transfusions: What You Need to Know
Have you considered how the new ICD-10 coding system impacts reimbursement rates relative to patient blood management and transfusions? The ICD-9 medical coding/reimbursement system was replaced by the Center for Medicare and Medicaid (CMS) in early October, 2015 with the new ICD-10 system, imposing yet another challenging and arduous endeavor on healthcare organizations and providers. Since implementation, many organizations are finding they are experiencing declining reimbursements. The new changes greatly impact current coding methods which lead to decreased coder productivity and a requirement of increased documentation specifity from the healthcare team. Gaps in this documentation, in addition to staffing shortages, not only with nursing but also coders, have led to an increase in claims denials and/or rejections yielding millions of dollars lost for some facilities. What’s more, CMS has increased its fraud and abuse investigations, as evidenced by an increase in recovery audit contractor (RAC) audits. So, why the change? And, what are the differences between ICD-9 & ICD-10? More specifically, how does this relate to patient blood management (PBM)?
ICD-9, derived in 1970, was outdated with medical practices no longer in use, plus it lacked the ability to incorporate new practices. ICD-10 is a more detailed coding system that focuses on laterality, primary and subsequent patient encounters, mechanisms of injury, etc. A snippet of key changes in the coding system include:
- ICD-10-CM (clinical modification) codes are to be used with all inpatient and outpatient diagnoses.
- ICD-10-PCS (procedure coding system) is only to be used by hospitals for inpatient procedures
- CPT (current procedural terminology) coding is to be used by all healthcare providers for outpatient procedures (no current changes to existing procedures)
- Codes are all alphanumeric with ICD-10.
- Injuries are grouped by site then type with ICD-10 as opposed to just type with ICD-9.
- Coding characters increased from a maximum of 5 in ICD-9 to a maximum of 7 in ICD-10.
- ICD-10 uses full code titles instead of partial
- ICD-10 uses code extensions for specificity and laterality.
- Right side is always character 1
- Left side is always character 2
- Bilateral is character 3
- Unspecified side code (if the side is not identified in the medical record) as 0 or 9 (depending on character placement).
Since transfusions are procedures, information in this documentation will focus primarily on ICD-10-PCS. Below is an excerpt from CMS describing components of the ICD-10-PCS: (a full reading of the description can be found at:cv
Medical and Surgical Section
The seven characters for medical and surgical procedures have the following meaning:
Character 1 = Section
Character 2 = Body System
Character 3 = Root Operation
Character 4 = Body Part
Character 5 = Approach
Character 6 = Device
Character 7 = Qualifier
The medical and surgical section codes represent the vast majority of procedures reported in an inpatient setting. Medical and surgical procedure codes have a first character value of “0”. The second character indicates the general body system (e.g., gastrointestinal). The third character indicates the root operation, or specific objective, of the procedure (e.g., excision). The fourth character indicates the specific body part on which the procedure was performed (e.g., duodenum). The fifth character indicates the approach used to reach the procedure site (e.g., open). The sixth character indicates whether any device was used and remained at the end of the procedure (e.g., synthetic substitute). The seventh character is a qualifier that may have a specific meaning for a limited range of values. For example, the qualifier can be used to identify the destination site of the root operation Bypass.
The first through fifth characters are always assigned a specific value, but the device (sixth character) and the qualifier (seventh character) are not applicable to all procedures. The value Z is used for the sixth and seventh characters to indicate that a specific device or qualifier does not apply to the procedure. [However, they are required for transfusions.]
One of the more troubling areas that organizations are experiencing in terms of ICD-10-PCS coding, reimbursement denials, etc. that are leading to lost revenue generation is transfusion coding which is directly related to PBM. Transfusion coding is more complex with the ICD-10-PCS system and as a result is one area that raises many questions, concerns, and missed financial opportunities. Recall, although PBM’s main focus is ensuring excellence in patient care related to transfusion medicine, it also shares a strong focus of proper stewardship of resources, such as personnel, product, and financial. Therefore, the task of ensuring optimal reimbursements related to transfusions and blood management is finding its way onto the radar for many Transfusion Safety Committee members. Since the new coding system is requiring greater specificity in documentation, for the purpose of capturing all necessary information in which to code and thus bill, it is logical to start with identifying key documentation improvement opportunities.
In order to obtain suitable documentation for ICD-10-PCS, recall, you must have information in the patient record that would fulfill the following for coding and subsequent billing/reimbursements:
To explain what this looks like in terms of MD and/or nursing documentation needs, please review the following:
- Blood component transfusions are found in the Administration section of the ICD-10-PCS with the first character “3”- indicating a “procedure” that would insert or place a therapeutic, prophylactic, protective, diagnostic, nutritional, or physiologic substance.
- The second required field, with proof of documentation, is the “body system”. In the case of a transfusion, this would be “circulatory”, represented by a “0”.
- The third character, “2” refers to the “root operation” and therefore would be; “transfusion”, putting in blood or blood products.
- The remaining requirements lead to documentation choices of: body part/region, approach, device (substance), and qualifier.
- See table below for a visual:
Section: 3 (Administration)
Operation: 2 (transfusion: putting in blood or blood products)
Body system: 0 (circulatory)
|Body System/Region||Approach||Device (substance)||Qualifier|
|3. Peripheral Vein
4. Central Vein
5. Peripheral Artery
6. Central Artery
|G. Bone Marrow
H. Whole Blood
J. Serum Albumin
K. Frozen Plasma
L. Fresh Plasma
M. Plasma Cryoprecipitate
N. Red Blood Cells
P. Frozen Red Cells
Q. White Cells
V. Antihemophilic Factors
W. Factor IX
X. Stem Cells, Cord Blood
Y. Stem Cells, Hematopoietic
While we want to ensure all necessary information needed for proper coding – and thus full reimbursement, is in the medical record, we certainly do not want clinicians to have to document in coding terms. Therefore a recommendation, albeit simple, for ensuring proper reimbursement would be to have clear documentation on the blood transfusion section of the nursing electronic medical record (EMR) that would specify (perhaps using tables and drop downs for quick/easy selection): that a procedure was done, which was a blood transfusion, into the circulatory system, with specifics noted in terms of body system, approach, blood component (substance), and “qualifier” (autologous or nonautologous)- creating a “one stop shopping” chart review for the coder. Hospital coding expert Becky Carmer states organizations “need to make sure the [transfusion] form has all the information on it and they [nurses] can just pick what’s appropriate”. She states, “coders can figure out much of the information from the medical record, but special attention also needs to be paid to the vein site used, [such as left antecubical], and the type of product”. She further states that much of the information, if it is not all on the transfusion form, can be deduced from somewhere in the patient’s chart, but that for efficiency, it would be helpful to have it all in one location.
Each organization is unique with varying EMRs/documentation. A multidisciplinary team should be established to ensure an early path to success. Consider:
- Build a team to collaborate with coders, finance/medical billing, key executives, nursing, blood bank, physicians, information technologists, etc. to ensure documentation needs are met to secure accurate reimbursement
- Inquire as to the number of these types of procedures that are performed in your organization daily and ensure you can locate proper documentation in each patient’s medical record. Test your documentation, ensure it holds up for coding and possible review.
- Perform timely self-auditing to help you answer these important questions, proactively ensure that you are documenting and coding blood transfusions correctly, and keep the revenue road clear of preventable denials, reviews, and/or delays.
- Adapt current documentation, such as the transfusion record, to ensure they meet coder’s needs, as suggested above.
- Train your coders: instruct your coders on where to find pertinent information, create scenarios your coders can practice on in terms of finding the information they need from the medical record.
- Provide timely feedback to the nurses, physicians, and coders about needed changes.
Revise your policies and procedures to address what to do in the event documentation is missing.
So, how should you set up your audits? Here are some tips:
- An increasing number of hospitals are implementing “self-audits” and/or “journalizers” to identify common mistakes and correct them prior to filing.
- Set a goal or a predefined error rate so you can effectively measure progress as well as show the cost benefits of your efforts.
- Consider using prior ICD-9 reimbursements received for transfusions as a baseline.
- Key tips from CMS (GREAT RESOURCE- with troubleshooting tips, not exclusively transfusion related): https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10NextStepsToolkit20160226.pdf
Mastering ICD-10-PCS coding related to your patient blood management program is much more than simply documenting the transfusion as described above. To make the biggest impact in your reimbursement strategies, consider the following:
- Learn about recovery audit contractors (RAC), a CMS entity designed to identify, correct, and collect on improper payments made by Medicare to providers and their organization as well as identify, correct, and provide payment in which there was insufficient reimbursement.
- Learn from your RAC denials to improve your current processes.
- Monitor the RAC’s websites to review their required updates as to upcoming audit details.
- A high number of RAC denials are related to blood: i.e. coagulopathy, acute blood loss anemia, etc.
- Strengthen your appeal strategies- what went well, what could be improved?
- Learn about proper coding for medical treatment related to transfusions such as how to code for the treatment of infections, TACO, and/or TRALI
- i.e. Coding for infections following a transfusion:
- “T80.2, infections following an infusion, transfusion, and therapeutic injection… should be coded first, followed by the code for the specific infection.” http://www.cdc.gov/nchs/data/icd/10cmguidelines_2016_Final.pdf
- i.e. Coding for infections following a transfusion:
It is true in many things, and especially so in the work of patient blood management: in our quest for excellence in patient care, “our work is never done”. Or better said: “The expectations of life depend upon diligence; the mechanic that would perfect his work must first sharpen his tools.” ~Confucius.
Author: Carolyn Clancy, MSN, CNS, RN