For this edition we are focussing on some basic steps to follow when submitting an ICD 10 code to medical aid and it is advisable that this is always kept in mind when submitting ICD 10 codes.
Always use Valid Primary codes in the Primary position.
First of all a Primary code is defined as the main condition that was primarily responsible for the patients need for treatment and investigation. If there is more than one main condition treated, then the most clinically severe or life threatening condition should be selected. The Primary code describes the primary diagnosis and must appear in the first position on a claim.
When do you use a Secondary code or Combination coding:
A Secondary diagnosis is defined as an additional condition that affects the patients care or may co-exist with the main condition and requires clinical evaluation, treatment and certain diagnostic procedures to be performed. External Cause codes also falls under secondary codes/diagnosis.
There are different combination codes to be aware of:
- All Primary codes starting with the letter S or T (injury codes) must be submitted to medical aid in conjunction with a secondary cause or nature of Injury code starting with the letter V,W,X or Y. These secondary cause codes must always be 5 digits/character codes i.e. V01.23 External Cause codes can NEVER be in the primary position.
Primary Diagnosis: S52.10 Fracture of upper end of radius, closed
Secondary Diagnosis: W01.08: Fall on same level from slipping, tripping and stumbling, home, while engaged in other specified activities
- Asterisks codes, (*) form part of a “cause and effect” relationship between two clinical conditions and are used in combination with another code, called a dagger code, (†) which would fall into the primary position. Once the primary code has been established and identified as a Dagger code, the next step will be to add the secondary “Asterisk code”. In most instances the secondary code you have to use will be in brackets at the end of the “ICD 10 Description” you have chosen as your primary code.
Because your software cannot handle special characters, the dagger sign(†) has been replaced with a (+) sign for you to identify the code as being a dagger code. Bear in mind that dagger codes can be for Example: Primary diagnosis: A06.5(+) Amoebic lung abscess (J99.8*). Secondary diagnosis: J99.8 Respiratory disorders in other diseases classified elsewhere.
- Sequencing rule: Once the primary Diagnosis has been established this should be followed by the other or secondary diagnosis, interpreted as additional conditions that affect patient care or conditions that co-exist with the primary diagnosis
Sequelae is also the late effect of a condition that is no longer present as the current Illness. Often this initial condition occurred one or more years ago. For example: One year ago the patient had a stroke. Now the patient present to you with dysphagia secondary to the stroke suffered one year ago. Today the primary diagnosis is the Dysphagia, R13, and it is part of a sequelae condition and therefore the secondary code will be I69.4: “Sequelae of Stroke, not specified as heamorrage or infarction.”
Secondary codes must follow the primary code and appear in the second to tenth position on a claim line
PDX: R13 Dysphagia
SDx: I69.4 . Sequelae of Stroke, not specified as heamorrage or infarction
- Local Infections
Causative Organism Codes can never be in the primary position (B95 – B97). Coding for some infections require an additional code in order to identify the organism that is causing the infection. For example: Primary code: N30.3 Cystitis can be submitted with the Secondary code B96.2 for “Eschericia [E.coli] as cause of disease classified to other chapters”
When is a code valid for clinical use.
You have to submit a complete code specified to its maximum level of specificity. A Valid code is most often a 5 digit/character code but in many instances a 4 digit/character code and in some instance a 3 digit code will also be valid. This can be determined by looking at the 2014 ICD10 Master Industry Table(MIT) that is downloadable from www.Medprax.co.za . In most instances your software will warn you if you are submitting an invalid ICD 10 code. If a code is rejected always refer to the MIT tables to see if the code you submitted was a valid clinical code and if it was a valid primary code.
When can I use “R” codes and “U” codes:
R codes are sign and symptom codes and will normally be used when a diagnosis has not yet been made for example when a patient is admitted or referred and a diagnosis has not yet been made. These codes should be reserved as a last resort.
The most important thing to know about U codes is that should a patient refuse that their clinical information be disclosed one would use a code U98.0. And in the event that you are dealing with Multidrug resistant TB, the U50 code range will be used in the secondary position.
Age and Gender codes:
When an ICD 10 code includes descriptive words like puberty, infants or adult it can only be used when submitting information for people that falls within this specified age group.
The same goes for gender codes, Gynae codes can only be submitted for females and Urological codes predominantly for males.
If you have any queries regarding ICD 10 codes or need assistance with rejected ICD 10 codes please send an e-mail to Candice@medprax.co.za.