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Understanding ICD-10 coding and its usage

 

 

T Parbhoo

Head Clinical Support Services, SADA Email: clinical@sada.co.za

 

 

 

In this article, I would like to share with you the below information as compiled and shared by Dr Tinesha Parbhoo, our Head of Clinical Support Services.

While January has come to a swift end, it is our hope that you all have settled in to 2021 and are working with determination and gusto, albeit in unprecedented circumstances. Since joining SADA as Head of Clinical Support, it has indeed been a busy yet fulfilling start to the year.

I am extremely excited to have become part of the SADA team and look forward to assisting you with your coding and other queries. With experience in both private and public oral health and having previously been a practice owner as well as an employee of a dental group, I can identify with the many challenges that practitioners face on a day-to-day basis.

I am determined to guide you when the situation calls for it and am committed to fight on your behalf and champion for the dentist. I therefore encourage you to reach out to me if the need arises and urge you not to feel shy or embarrassed -1 am here to help.

- Dr Parbhoo.

Since the start of the year, the Clinical Support Department has received numerous queries on incorrect usage of ICD-10 coding, both from third party funders rejecting accounts and from members. As such, we found it imperative to clarify basic ground rules with regards to ICD-10 codes. Members are reminded that ICD10 are diagnostic codes and while we frequently receive calls to supply you with the ICD10 codes for procedures, this is not always possible as we at the office have not physically examined your patients to make a diagnosis.

According to the WHO, the International Classification of Diseases (ICD) is the "foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions. It is the diagnostic classification standard for all clinical and research purposes. ICD defines the universe of diseases, disorders, injuries and other related health conditions, listed in a comprehensive, hierarchical fashion".

The purpose of ICD-10 is to translate diagnoses of diseases and other health problems from descriptions into an alphanumeric code, which permits easy storage, retrieval and analysis of the data. It also allows for the establishment of a systematic recording, analysis, interpretation and comparison of morbidity and mortality data collected within the country but also with other countries.

 

 

The minimum basic code in the ICD system is a primary code: this consists of an alphabetic letter followed by 2 numbers e.g., K00.

The primary code indicates:

- The body system that the condition relates to e.g., the digestive system;

- Which section of that body system is affected by the condition e.g., teeth, jaws, salivary glands.

Secondary codes are codes that further describe the patient's condition or the cause of the patient encounter e.g., K01.1 (impacted teeth).

Other dentally significant codes include:

• Z-codes, which represent factors influencing health status and contact with health services i.e., reasons for encounters e.g., a dental examination (Z01.2)

• S-codes, which indicate injury, poisoning and certain other consequences of external causes. All S-codes must have 5 characters except for S03.2, which is a competent 4-character code. Any fracture code must be described with a fifth character of 0 (closed fracture) or 1 (open fracture). The default use for a tooth fracture, which cannot really be described as open or closed, is 1.

• T-codes, which demonstrate the effect of a foreign body entering through an orifice.

The South African standard stipulates that all S and T codes must be accompanied by the External Cause Codes (ECC). ECCs allow for the classification of environmental events, circumstances and conditions as the cause of injury, poisoning and other adverse effects.

They begin with the letters V (transport accidents), W (falls and exposure to inanimate objects), X and Y (exposure to other incidents such as complications of medical and surgical care.) All ECCs must also be 5-character codes, describing how and where the incident occurred.

The primary code and ECC are always separated by a forward slash.

When coding for a certain procedure, it is helpful to remember that the ICD-10 codes for a procedure must be the same as that reflecting the reason for the procedure i.e., "What diagnosis led to the treatment being performed?" The ICD-10 code should hence reflect the cause of the condition rather than the procedure itself.

This applies for all procedure codes billed during that procedure. Let us look at a few examples from queries received:

• I need an ICD-10 code for a radiograph. We always used Z01.2, but the medical aid says it's not correct. We must do a root canal treatment and I can't seem to find anything on the internet.

In this case, the ICD-10 code for the radiographs will be the same as the reason for the procedure i.e., K04.0 (pulpitis). Note: Not to be confused with radiographs taken during a general examination, which will attract the code Z01.2.

• I used the ICD-10 code Z30.2 for code 8110 and it was rejected.

Z30.2 is listed as "Sterilization - Admission for interruption of fallopian tubes or vas deferentia" and is therefore incorrect. The ICD-10 code for 8110 should always follow on from that of the procedure.

• How do I bill for telephonic consultations?

Z76.8 (persons encountering health services in specified circumstances).

• How do I code for an implant supported bridge?

Once again, we refer to the reason that the implant and bridge were placed i.e., loss of teeth. Hence the code could be K08.

• How do I code for re-cementation of a crown?

Z46.3 (Fitting and adjusting of dental prosthetic device).

• What is the ICD-10 code to be used for teeth whitening?

Z41.8 (Other procedures for purposes other than remedying health state)

• My patient had a car accident on his way to work and fractured his mandible. How do I code for that?

It is important to note that this is a five-character code. The fifth character, a 0 or 1, indicates an open or closed fracture.It also requires an external cause code, describing how, why and when the incident occurred i.e., S02.61/V43.42, where V43 indicates a car occupant injured in collision with car, truck or van, 4 indicates street or highway and 2 indicates while working for income.

N.B. Because the ICD-10 codes relate to an injury, an external cause code is also required.

• The patient broke his tooth in a hockey accident. What are the correct codes?

Again, the five-character code applies: S02.51/W21.30, where W21 indicates striking against or struck by sports equipment; 3 indicates at sports or athletics arena and 0 indicates during sports activity.

While ICD-10 coding might seem cumbersome and unnecessary, it is a statutory requirement to collect this data for an accurate reflection of the burden of diseases experienced in South Africa. It is also a vital part of the claims process. Medical scheme entitlements are based on diagnosis and procedures which determine how much money is made available for each benefit. Thus, if the patient or the doctor does not divulge such information, the scheme can rightly question what they are paying for, and may refuse payment for the services rendered.

If there are any further queries regarding ICD-10 coding, kindly email Dr Tinesha Parbhoo at clinical@sada.co.za. A general list of ICD-10 codes may be accessed at the following link: https://icd.who.int/browse10/2019/en

The WHO has also made available an ICD-10 interactive self-learning tool, together with full ICD-10 training, which will be helpful for practitioners and support staff alike. This tool is available at: https://apps.who.int/classifications/apps/icd/icd10training