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Hello and Thank you for inviting me to be part of the to the ICD-10 Forum. AC takes your concerns seriously and wants to address them. We are listening to your concerns and implementing corrections and enhancements to the vocabulary as we are able.

Amazing Charts cannot provide specific guidance on what codes to use

The ICD-10 code concerns we have heard most frequently are being addressed in development now and will be fixed early next week. For instance:
1. Descriptions for ?Encounter for routine child health examination with abnormal findings? and ?Encounter for routine child health examination without abnormal findingss? are being added to the vocabulary /problem search. This addition should render the refinement step for that diagnosis unnecessary. In the meantime, I can suggest 2 potential workarounds if you wish to use this code
a. Enter Well child into the problem search ?Well child visit appears, Double click, select Refine, you can choose the appropriate code with description.
b. You may also input the ICD-10 code Z00.129 Well child visit without abnormal findings which will return the description ?seen by pediatrician ?, use this if you are comfortable with the description.
2. Adapted Description for ?Z23 Encounter for immunization? is also in development. "Encounter for immunization" will be at the top of the list of search results.
a. The workaround
i. Type other specified vaccination(or partial words oth vacc) and Z23 will appear
ii. Type Z23 and scroll to other specified vaccination
*These coding corrections do not require you to take any action, you do not have to update your system. These codes will automatically be pushed out to you as soon as the development effort has been completed.

OK. I think I made a mistake by locking this thread. As you may or may not know, Catherine is the ICD-10 expert at Amazing Charts. She knows all things ICD-10. I think there are a few premises about ICD-10. And, keep in mind I am about as ignorant about billing, coding and ICD-10 that there is.

As I read the questions and comments in the ICD-10 forum I become enlightened and more confused at the same time.

First, I think AC has done an excellent job in handling the ICD-9 to ICD-10 changeover. Second, I think a lot of the confusion is due to many of us either not understanding exactly what ICD-10 entails and just how much granularity we have to get to in order for insurance companies to pay. As Jon has said, I think we may all be concerned too much with granularity. I heard a fairlfy detailed explanation of the difference between the codes found on the main page and the codes you find in the chart. And, I came away even more confused. See above.

ANYWAY, I think it may make the most sense to ask a lot of our questions here so that Cathy can, hopefully, answer them.

As you can see from Cathy's signature in the first post above, her email is attached. But, rather than deluge her with emails, posting here will benefit everyone.

The AC website has a lot of good information about ICD-10 including a pdf on ICD-10 FAQs

But, I think that this thread could produce our own FAQ, albeit maybe not quite as organized.

Hi All Just an FYI check out the FAQ on our webpage for some helpful hints as well as http://www.aafp.org/fpm/2014/0700/oa1.html
for tips about Preventive Care coding

i am so glad you are working on the z00.129, and z00.121

the biggest problem i have about the above, and other codes that need refinement - 'the search clinical diagnosis' is that, although it is easy and quick to choose a refined code, BUT then, the computer will lag for about 30-45 seconds before the window will close out.

so this comment is to question the lag time after choosing a refined code
thanks

I noticed when billing vaccines that old ICD-9 dx codes pop up in Section 4 on the billing screen

v 8.2.4

Any fix coming ?

Will look into this with Client Services.

Hi, I have not encountered that issue. Is ICD-10 selected as the Bill type (to the Right of Alternate codes in Section 4>)? If that's not the problem then perhaps sending a screenshot would help. Thank You

AC pulls ICD 9 codes from the last encounter when a vaccine is given before the physician finishes the note. It happen even when the Bill is selected to be ICD 10. I heard they are working on it. I think the issue should resolve once most of the past encounters have ICD 10 codes.
I also learned how to look up specific codes. Once a non-specific code is pulled in the encounter, click on "Specify the code" and it pulls more specific codes that can be selected and entered in to the visit note.

I just got a our first bunch of rejected claims to fix that were uploaded to Office Ally for dates of service October 1-2, 2015. Reason is "diagnosis code is not billable." When I pull up the claim to fix, it appears that the Dx codes are not uploading in their entirety. Z00.129 uploads from Amazing Charts to Office Ally as Z00.12 (the 9 is cut off). I just sent message to Amazing Charts. Hope this will get fixed because now I have to manually fix all our pediatric well check claims in office ally

PROBLEM: ACPM DOES NOT ALLOW ENOUGH CODES PER OFFICE VISIT

My understanding is that now, each patient visit may have 12 ICD10 codes (since there are so many more more codes necessary to comply with the degree of "granularity" required.) Unfortunately, AC only allows: 4 ICD10 codes per CPT code, for a total of 8 codes.

At least for my specialty, this is unacceptable. For example, I just saw an HIV patient who had an allergic contact dermatitis on both the rt and left upper and lower eyelids, along with a skin lesion suspicious of Kaposis, plus a tender wart on the bottom of the foot, and needed a refill of her acne medications. She also had an actinic keratosis on the left cheek that I quickly froze. Here are the required ICD10 codes:

H01.111
HO1.112
HO1.114
HO1.115
D48.5
L70.0
B07.0
Z21
L57.0

I called support and asked "how do I include all of these codes" and I was told it was a known bug that there are not 12 slots. Well, KNOWN BUG OR NOT, this should be fixed immediately since I cannot comply with ICD10 as is.

Sandy Martin MD
Martin Dermatology

Forgive me for my ignorance. I seriously know very little about ICD-10. Just need some help here.

What would happen if you only coded three of the ICD010 codes as far as reimbursement? Or at the least six?

My understanding is that this would be a violation of ICD10. The problem is that this is of NO import...UNTIL an auditor (CMS, RAC wannabe, etc etc) checks your records and shows that your coding does not match the documentation in the record.

This was the entire point of this 2 year long exercise on getting prepared for ICD10: that we be very careful to document with a high degree of granularity (laterality, causality, co-morbidities, etc), so that when the auditor evaluates our codes submitted for payment, the codes are fully represented by the documentation. This also means that the documentation is fully represented by the codes.

The long and short of it is that there is a reason ICD10 provides for 12 codes per encounter...and our software is currently NOT allowing us to comply.

I mean, you don't think that there is so specific a code as getting a cowhorn shoved up your ____ , on the right side, at night, in the snow, during June, in the presence of his sister...for no reason at all, do you? The reason is we are expected to have highly specific documentation supplemented by highly specific coding.

I am happy to be shown where my analysis is misguided, but right now I am not a happy camper.

Sandy Martin MD. Esq.
Martin Dermatology

I certainly understand your input and understand your frustration. And, thanks for the explanation. And, you are correct.

I just simply don't have time to code 12 ICD codes in one visit. In fact, I doubt I have done more than four in my career. I guess for me the granularity was, lower extrimity pain, then on left, then on calf, then without rash, etc. I wouldn't be able to see a patient with ten separate diagnoses. Oh well, I just don't understand. But, I am not concerned. It was important to document with ICD-9, and I was never audited.

But, I understand what you say.

Sandy,
Like Burt, I am no expert on ICD 10; I know little about dermatology. I think it's important to discuss the general issue that you are bringing up, both as it relates to Amazing Charts and as it relates to coding and billing throughout medicine. I hope you and others are willing to discuss that here.

My opinion is that our fear of ICD 10 has been falsely raised to a fever pitch. There is an entire industry of consultants who justify their existence by telling us how to comply with the new coding system. Over the past couple of years we have read about how this is "changing medicine as we know it". We have been told that we should be taking out large loans to cover our interrupted cash flow (that's a very common recommendation, one of which of course has negative implications for us and positive ones for the banking industry). In my opinion, much of this is overblown.

When you say "I cannot comply with ICD 10" and "this would be a violation of ICD 10", I think you are responding to that drumbeat of bureaucrats and business people who want to lead us by the nose. ICD 10 is a codebook. You can't violate it. You don't have to comply with it. Yes, CMS and the insurance companies have rules, and I understand what you mean that we must follow them to get paid. They reimburse us for taking care of patients. In order to get reimbursed, we perform a service, we provide a code indicating roughly the amount of work that we did (a CPT code), and another code to indicate the diagnoses that were treated. As far as I'm concerned, what's most important is documenting important clinical information for patient care and documenting what we must to get paid. Beyond that, I will provide what CMS, insurance carriers, and statisticians demand; but only to the minimum extent required. I need to be sure that my notes document a sufficient degree of complexity and detail to document a given level of reimbursement. So if I bill a 99214, the note must reflect that. The ICD-10 codes must reflect accurately what I saw. But...and I think this is the key point... IT NEED NOT REFLECT EVERYTHING THAT WAS SEEN.

So let's look at your excellent example. First of all, you mentioned that the patient has HIV and you coded for that. You did not mention if the patient also has hypertension, diabetes, and high cholesterol. Would you feel a need to code for those diagnoses? I would argue that you need not code for any of them... including HIV, unless you feel that it will somehow document management that will allow you to be reimbursed at a higher level. Should your notes reflect that the patient is HIV positive? Of course, and I would imagine they do. That's your decision. But why do you feel the need to code for that in ICD 10? The same is true for those other medical conditions.

And how about his dermatitis of all four eye lids. Your note presumably documents the extent of his condition. In my mind, it's ridiculous that you cannot code "allergic dermatitis of eyelid" and not specify which one. But does it really mean you MUST provide an ICD 10 code for all four of them? If you pick one, for example, HO1.21, your note would be accurate, your coding would be accurate, and your reimbursement would be unchanged. (Maybe some day they will pay you "by the eyelid" but isn't that unlikely?) Do you really think that if you were audited there would be some negative consequence for failing to code for the other three eyelids? What do you think that consequence would be?

Look, I am a simple gastroenterologist. For years I would see patients with epigastric abdominal pain and I coded 789.06. I would send the bill and that was the only code. If the patient was HIV-positive with diabetes, hypertension, and a host of other problems; even gastrointestinal ones, I was not required to provide all those other codes. I was paid appropriately. I don't see why we should assume that situation has changed. Yes, some codes are more specific (with laterality, etc.) But there is no mandate to include a dozen diagnoses for each CPT code.

Please feel free to disagree and show me where I am wrong. As far as I can see, coding the way that I am suggesting would have no negative consequences for the patient, no negative consequences for clinical documentation, and really should have no negative consequences for you.

Thanks Jon for the thoughts!

Much of what you say, I do not disagree with. Certainly the implication that we are pawns in a much larger game. Nevertheless, I feel the need to comply with accurate and specific coding and our software does not allow for it currently.

You are right, in my example I would not include hypertension because it bears no relevance to the clinical circumstance. But HIV does as it effects the immune system and the warts and the dermatitis may be related thereto.

As to 4 (ridiculous) eyelids: that is the code. Dermatologists are involved with eyelid dermatitis, whether it be allergic or irritant and the code specifies precisely. I simply try to be as specific as I can, call me a wuss.

I dont think I have to remind any one of us that in the next year or two, our payments are going to be based upon an entirely different system. And that system will "look-back" at the nature of each of our practices to determine our values. I would argue that if you care about your future income, you would want to develop statistics that accurately reflect all of the myriad diseases your patients have (up to 12 at least!)and that you take care of.

The other codes I've indicated obviously must be entered as they are codes I have shown would be billed for in the example.

So, yes, I understand we can often get away with things. But I sleep easier if I just play the game I am invited to, with the ball and bat they gave me, until I am out of the game.

The lack of relevance of any pertinent information collected by insurance coding is a given for most practicing physicians. What is amazing to me is the pronouncements by government talking heads that this information can be used for any public health purpose. My clear motivation for ICD 10 coding is getting paid. Reading over some of the EMR notes I receive from others, it would seem that the purpose of EMR generated notes is "over documentation" to support any and all coding. I find myself on the phone much more now to find out what they really mean, since notes have become so distorted and bloated.
Since our benevolent government has allowed the insurance lobby to run roughshod over practicing physicians, they will reap the harvest of bloated documentation and coding. Much like the completion of death certificates. Those of us who complete these documents with limited information available on the elderly patient who dies at home shake our heads when news reports tell us that so many deaths occur from this or that cause per year. Garbage in, garbage out.

I suppose I am unique or maybe it is because I am a pediatrician. But, my patient comes in with a CC and history. I do a physical exam and arrive at a diagnosis. I then code that with an ICD-10 code. It may be just an ICD-10 code for an ear infection or it may be for that and chronic cough as well. Either way, whatever illness they have at that visit, I put down for codes.

I apply a CPT code which is justified by the diagnoses and documentation. I don't tend to worry about other diagnoses in the problem list which may affect the current illness like asthma or mitochondrial disease. I supposes I could, but it just doesn't seem relevant. They have chronic cough and otitis media, and I do not deem it to be asthma or asthma related. This may be a bad example since asthma is so inter-related to cough. The other earlier posts, notwithstanding, I am ignorant as to what putting in asthma will do for me down the road.

I like ICD-10 much better, and I do not seem to be overly concerned with reimbursement. I find most insurance companies (especially when dealing with a small practice like mine) are more interested in the bell-shaped curve of CPT codes than the ICD-10 codes.

Of course, I don't worry about HIPAA or drug diversion either. I don't mean I don't try to follow them, I just don't lose sleep over hard drive encryption or whether or not I have a drug contract on every patient on Vicodin.

One thing which has not been brought up is that if I sign off on a nurse practitioner, the ICD-10 and CPT codes are not recorded in the billing section like mine is.

I didn't take a single coding course.
I still run 6.3.3
I code mostly in ICD-9, because it's in AC 6.3.3 -- but increasingly, ICD-10 codes come up in the Google search when I come across something new, and then I often add them to the code database through the AC search box -- it's very simple, and as time goes on, I get a larger and larger searchable ICD10 code database in AC 6.3.3

We don't use AC for billing -- we use Medware, and they have a built-in program for crosswalk ICD9 to ICD10, so it is simple, and the billing clerk doesn't spend any time or lose any sleep over the conversions. Medware allows more codes than AC apparently does -- but I don't worry about that. The billing clerk says we are getting paid, but I suppose in the future additional "granularity" (doesn't that just sound so scientific!) -- and if so, I guess we can just start adding more codes to a bill.

I keep two tabs pinned to Chrome on my desktop
http://www.icd10codesearch.com/?
https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx?

which are useful to either search directly for an ICD10 code from key words, or verify a crosswalk -- but I don't have to use them very often.

At the end of the day, my job is to see patients who want to see me -- I am not a coder or a clerk.

"Sufficient unto the day is the evil thereof"

Hi Tom,

Thanks for your thread. Please tell me to butt out if I am stepping over my bounds. Wow, twice this weekend I feel like I am answering a post of yours I shouldn't.

First, you say 6.3.3 I had been on 6.1.2 since it came out. At the CAB meetings, Charlie would ask who is on what version. I would almost be embarrassed to say 6.1.2. But, as you note or at least indicate, 6.33 or v6 just works.

I planned on doing EXACTLY what you are doing. I didn't like the performance of v8. I spoke out vehemently. I still find it slower.

I did a LOT of reading on ICD-10. On here, on the AC website. Online. Books. One thing I kept coming across is to beware of coding in ICD-9 and converting it.

I trialed 8.2.4 in a VM. It was slower. But, for me, it wasn't the horror storries of others. Given I thought I would use 6.1.2 like you are doing, I wasn't going to change. But, not only did it give me ICD-10, it had the phone and fax numbers of the pharmacies in ePrescribe. It had many, many other features.

I took AC off a little used computer but one within quick access of the "girls" in the office. I explained everything to them, the benefits, ICD-10, the options the performance. I asked them to play with it. They did. They loved it. They didn't mind the speed. I told them we can't predict the speed on the server over the network given it was on a local computer with SSDs and an i7. They didn't care.

We made the switch. For us, and I know it has been worse for others, the speed hasn't been an issue.

The key is this.

I now do ALL the coding and billing. I enter the diagnosis with the ICD-10 code. I enter the CPT code with the precision of a brain surgeon. I used to just click off 99213 and didn't really care, because I knew what I put on the Encounter form/Superbill (paper) is what would count. Now the ICD-10 (except for urgent visit) and the CPT codes don't matter on the Encounter form. In fact they aren't even on there. Only procedures and vaccines and the urgent visit since I wouldn't know that.

The ICD-10 in AC is AWESOME. It is AWESOME. I am confused by what some people say about five clicks. I find all my codes in one click, maybe two. They are all billable.

That is the nice thing. There is NO room for error. If I code for a certain diagnosis, and the ICD-10 code is put in the chart along with the correct CPT code after I sign off, then it is correct.

My biller comes in the next morning. She clicks on Billing at the top of the main window and Pull/Export bills by date. She clicks on Pull Bills. All of the patients seen are there. So, it is nice. If you forgot to finish the note, she won't bill by mistake. If you finished and signed off the note, there is an ICD-10 and CPT there. She can open them individually electroncally as she does to save money. Or under Billing Reports, Run Invoice Reports, you can print all of them to a printer in one minute. All of the invoices. All with the ICD-10 codes and CPTs and modifiers.

It takes her less than half the time to finish her work at $16.00 per hour. She doesn't have to convert things. The "girls" all ordered special ICD-10 books and have their special URLs. My biller has the thickest ICD-10 code in the world. She says she hasn't even opened it.

We still use the encounter form. It serves a great purpose as well. There will always be more encounter forms than the electronic bills on AC. Because some kids come in just for a strep test or vaccine. But, if there are less, then she knows there is a problem. She still enters and scrubs and checks my note for E & M coding.

It just works so well this way.

OK Bert.
I guess we will all muddle through in our own way.
I will probably go for v8 later in 2016, when some "final" version is really stable. I'm done being an "early adopter".

I just refuse to be very awed by ICD-10. I'm not coding for posterity -- I'm coding to get paid. When we get bill rejected for incomplete codes, I'll know its time to change.

My main concern at the moment is trying to understand all the differing versions and interpretations of what Medicare means by "pay for performance." We just aren't going to do MU-2, let alone MU-3 unless something really changes -- but there is PQRS and who knows what else.

It all makes my head spin and induces a sort of chronic nausea to think about it. I used to worry about patients -- am I doing the right thing for them?
Now I mostly worry about whether I have "documented" correctly to sustain an audit or a malpractice claim.
And I just hate it.

Do you really use AC for billing?

Remember, I just changed from 6.1.2, so I am definitely not an early adopter. For me, the board is where the beta testing gets done. Also, CMS is not going to penalize anyone for improper codes for the first year in in the same category, whatever that means.

I hate all this stuff. CCHIT, MIPS, ICD-10, MU 1, 2, 3 and 4 through 10. Of course, we all wanted MU. I am not too worried about being audited. Hasn't happened in 21+ years.

No we use Medware.

It's just that now the CPT and ICD-10 codes that get entered into Medware come from AC. They aren't circled on a sheet.

Tom, if I understand this correctly, you and Donna are doing the same thing. My concern for you is that at some point when you DO upgrade, all of those codes you have entered will not be recognized as an ICD9 code. AC will not automatically convert them to the corresponding ICD10 code, and you will have a lot of extra work at that point.

I think that everyone can ask Jon that I was the poster child for not wanting to go to ICD-10. I am very happy I did. Of course, I was concerned about performance, but now I do fall into that group of people who say it is good enough.

Now, if I can just find a way to get those stupid check boxes to remain checked. In the past, I actually added my DEA to my address, which allows it to be put at the top of the script. It just looks kind of stupid to have it there when you need the header for other reasons. It would be a good preference.

The other frustration is I had my SQL expert delete the medication Concerta and change all of them to methylphenidate 36 mg, extended release. You couldn't write for it unless you actually typed it in. That was overridden with the new database.

You are right, Jon.
But I usually put in both ICD9 and ICD10 codes in the dropdown list, so when I do change over, most of the ICD9 codes will be converted by the software.

I probably will change over pretty soon, but I'm waiting for signals (Bert seems relatively positive now) that 8.1.* is mature. It will take me a weekend and who knows how much staff unhappiness the next Monday to make the switchover.

Just don't have the psychic energy for that right now.

Same here Tom.
All of my ICD9 codes are still present in the Inactive list.
So, if AC does not know what to do with my created ICD 10 codes, it will still convert the ICD9s.
Just a few seconds to reactivate if needed.
Same strategy, let the early adopters work out the issues, then when a fast, stable version seems to exist, will upgrade.

Need to be cautious with the system had patient yesterday looked up bruising got T14.8, today someone with compression fx looked up got T14.8, ie injury code unspecified, let's see how that gets paid

B99.8 "Other infectious disease" according to ICD10DATA.COM. AC is coding it to something specific like PROTOTHECOSIS. CAN we get the verbiage to say "OTHER INFECTIOUS DISEASE."

Sandy Martin MD

T14.8 appears to be a catch all code mapped for non specific injuries ( EX:T14.8 Other injury of unspecified body region
Abrasion NOS, Contusion NOS, Crush injury NOS, Fracture NOS, Skin injury NOS) If you want to be more specific then document the body part injured.
EXAMPLE
In AC if you input "contusion" you will retrieve T14.8 but if you input"contusion L forearm " you will retrieve S50.12
That code will be yellow and need to have the episode of care refined to S50.12xA for "Contusion of left forearm initial encounter".

To better understand how to code injuries Check out
http://cdn.roadto10.org/wp-uploads/2014/08/2015-ICD-10-CM-Tabular-List-of-Diseases-and-Injuries.pdf

Chapter19 uses the S-section for coding different types of injuries related to single body regions and the T-section
to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes.. Look at how the codes are structured,for instance S50-S59 Injuries to the elbow and forearm- S51.8 Open wound of forearm--S51.842 Puncture wound with foreign body of left forearm.
You can also view a post from Oct 12 on insect bites with much the same result.

I am having a problem selecting ICD-10 codes. When I select a yellow code, it opens up a new window to select a more specific code. The problem is, selecting a code in this window "freezes" Amazing Charts for several minutes before the code populates in the diagnoses window. Really holds up completing the note. I posted a bug report, but probably a reason not to choose a specific code until this is fixed.

Jeremy,

Since you joined today and posted within minutes, can you give us full disclosure. Your company sells an EMR product, Practice Management and billing services.

Did you just join and post this to guide users to the free portion of your site? I think everyone would like to know.