Wound Care Revenue Barriers in an ICD-10-CM Environment: Tips for QHPs & Coders

The fanfare for ICD-10 may have been a bit hyped. However, coding and reimbursement challenges remain.

Throughout the trials, tribulations, and delays that led up to the implementation of ICD-10-CM, the execution on Oct. 1, 2015, was actually quite uneventful for the most part — even commonplace, some might say. There were no parades thrown, breaking stories reported, or, unfortunately, national holiday issued. Everything just seemed “business as usual” for the most part from a national perspective. But, as the infamous quote states: “If something’s too good to be true, then it probably is.”

With that said, the healthcare industry (including the outpatient wound clinic space) is, at the very least, experiencing post-ICD-10 revenue barriers. This includes elevated denials and, in turn, elongated claims submission. Coders, auditors, and revenue cycle specialists are attuned to the specificity of ICD-10 along with local coverage determination (LCD) and national coverage determination (NCD) utilization requirements. Based on the first three months of ICD-10 utilization, a team of wound care revenue cycle coders identified their patterns of coding challenges due to insufficient or perplexing provider documentation that continues to compound. This article will provide a review of some of these coding challenges.

Coding Challenge No. 1: Non-Pressure Chronic Ulcers

Example A: Non-pressure Chronic Ulcer

Qualified Healthcare Professional’s (QHP’s) Final Diagnosis:

“Diabetes type 2 - right foot ulcer with fat layer exposed.”

From a coding prospective, a causal relationship is a documented link between a disease (etiology) and a condition (manifestation) caused by that disease. For a coder to report a causal relationship between diabetes and a condition, the provider must establish a definitive link in the documentation. In Example A, the QHP did not document a causal link between the diabetes and the foot ulcer. Therefore, the coder can only code the following ICD-10 codes:

E11.9 - Type 2 diabetes mellitus without complications.

L97.512 - Non-pressure chronic ulcer of other part of right foot with fat layer exposed.

Example B: Non-pressure Chronic Ulcer

QHP’s Final Diagnosis: “Right Type 2 diabetic foot ulcer with fat layer exposed.”

The QHP’s final diagnosis in Example B provides an acceptable causal link that resulted in ICD-10 code assignments that will clear the initial LCD medical necessity requirements.

E11.621 - Type 2 diabetes mellitus with foot ulcer.

L97.512 - Non-pressure chronic ulcer of other part of right foot with fat layer exposed.

Other acceptable causal links in diabetes include the phrases “of diabetes” or “due to diabetes.” “Diabetes and” does not establish a causal relationship, nor does the phrase “diabetes contributing to,” because this only establishes a factor, not a cause. These small differences of documented language are critical in diagnostic coding, as it can make or break the requirements for medical necessity under current LCDs or NCDs. In addition, the depth or severity of non-pressure chronic ulcer code assignment may be based on the medical record documentation from clinicians who are not the patient’s QHP. This information is typically documented by other clinicians involved in the care of the patient (eg, nurses often document the assessment of a wound). However, when there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending QHP should be queried for clarification. It’s key to note that staging should not be used to describe non-pressure chronic ulcers, even though the descriptions are similar to pressure ulcer stages. For accurate ICD-10 code assignment, the best practice for the QHP is to identify the cause of the non-pressure chronic ulcer, such as diabetes or peripheral vascular disease. To accurately assign the precise ICD-10 code, severity depth of non-pressure ulcers is required to be documented based on anatomical location, laterality, and causation (if applicable).  For example:

• Limited to skin breakdown only.

o Documentation should state partial-thickness skin loss involving epidermis, dermis, or both.

• Fat layer exposed.

o The fat layer of skin is located in the subcutaneous layer of tissue known as the hypodermis. The thickness of the fat layer, which varies greatly from one person to another, depends on the size and number of fat cells. Documentation should state that the subcutaneous layer is involved.

• Necrosis of muscle.

o As the muscle tissue dies, the tissue is more thick and tenacious. Documentation should state muscle involvement and extent of necrosis.

• Necrosis of bone.

o Because bone is living tissue that requires blood, an interruption to the blood supply causes bone to die. Documentation should state bone involvement and extent of necrosis.

In conclusion, the current revenue barrier for non-pressure chronic ulcers is that depth or severity documentation is absent or conflicting (between QHP and clinician), prompts clarification requests, and consequently delays claim submission.

Coding Challenge No. 2: Laterality

Because anatomical site laterality has been improved and because ICD-10 codes are available for additional sites, laterality must be documented and should not be overlooked. Otherwise, the notorious “not otherwise specified” (NOS) code will have to be assigned.

Example C: Laterality

QHP’s general notes: “Wound No. 1 on back is an acute stage II pressure ulcer and has received a status of ‘not healed.’

The subsequent wound encounter measurements are 1 cm length x 0.9 cm width x 0.1 cm depth, with an area of 0.9 sq cm and a volume of 0.09 cubic cm. There is a small amount of serous drainage, which has no odor, noted. The patient reports a wound pain level of ‘1.’ The wound margin is irregular. Wound bed is ‘no epithelialization, no eschar, yes slough, no granulation.’ The wound is improving.”

QHP’s Final Diagnosis: “Back pressure ulcer, stage II.” 

Example C illustrates that without laterality or site specificity, the ICD-10 code assignment will generate the notorious NOS or L89.102 - Pressure ulcer of unspecified part of back, stage II. Consequently, this unspecified code will elevate the claim denial probability.

NOTE: The ICD-10 laterality and specificity has been improved for back locations. The following back location terms should be communicated to QHPs:

• “right upper”

• “left upper”

• “right lower"

• “left lower.”

Coding Challenge No. 3: Pressure Ulcer Staging

Pressure ulcers are assigned a stage or category once the assessed wound is diagnosed or determined to be a pressure ulcer. The classification system of the National Pressure Ulcer Advisory Panel was not designed for use in any other wound type. Assigning a pressure ulcer stage is based on visual inspection to determine the extent of tissue destruction and wound depth. Pressure ulcer staging requires understanding of the anatomy of the skin and underlying tissues.

Example D: Discrepancy with Pressure Ulcer Staging

History of present illness in QHP’s electronic health record (EHR) states:

“The patient returns for re-evaluation of stage IV pressure ulceration to her left knee. She has been using ‘X’ dressing as directed. Her last dressing change yesterday was performed and removed today, displaced and not absorbed. The patient states there have been no changes in her medical history or medications since her last evaluation. There are no complaints of pain.”

Objective in EHR states:

“Wound No. 1, left anterior knee, is a chronic stage III pressure ulcer and has received a status of ‘not healed.’ Subsequent wound encounter measurements are 0.7 cm length x 0.6 cm width x 0.1 cm depth, with an area of 0.42 sq cm and a volume of 0.042 cubic cm. No tunneling has been noted. No sinus tract has been noted. No undermining has been noted. There is a small amount of serous drainage, which has no odor, noted.” 

Assessment in EHR states:

“Stage IV pressure ulceration, left knee, resolving.”

The provider documentation conflicts between stage III and stage IV pressure ulcer of the same site in three different pertinent key areas especially linked to medical necessity. If discrepancies are noted, querying the QHP is necessary to determine the correct ICD-10 code assignment before claim submission.

Next Steps for ICD-10 Coding Improvement

Although precise training and upgrading documentation was provided before Oct. 1, 2015, it is now time to evaluate ICD-10 implementation expectations against results. Understanding the importance of quick identification, collaboration, and effective correction will remove revenue barriers. Following are some post-ICD-10 implementation tips for coders:

1. Engage coders/auditors to discuss their own challenges of assigning ICD-10 codes based on current documentation.

2. Establish a rapid-response feedback system to inform QHPs about documentation that is lacking required specificity to assign ICD-10 codes. 

3. Ask the appropriate questions. Ideally, queries should be clear, concise, and compliant. Help QHPs learn how to accurately and completely document patient encounters.

Following are a few post-ICD-10 implementation tips for QHPs:

1. Assure you have the training you need to provide the level of documentation required for the precision of ICD-10. If the right EHR vendor is in place, it’s easier than QHPs may think!

2. Ask for feedback. Silence is not golden. Ask how you can improve your documentation, which will result in a win-win for the QHP’s revenue cycle and for the wound clinic’s revenue cycle.

Following are a few tips for the entire post-ICD-10 implementation revenue cycle team:

1. Take control. Keep a close eye on reimbursement and the bottom line while working with payers to establish equitable policies.

2. Be observant of payers’ denials. Payers are starting to remove some of their denial edits until they better understand the impact of the new ICD-10 diagnosis codes on claims. It may take insurance companies months to determine and implement their new ICD-10 denial edits. Therefore, be vigilant of denial activity by payers and the root cause throughout the first year of ICD-10. 

Andrea Clark Rubinowitz is senior director of revenue integrity and audit at MaineHealth, Portland. She founded Healthcare Revenue Assurance Associates, serving as chairman and chief executive officer from 2001-14.