September 2018 Volume LIII Number 5

 
 
 
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Behind the Code

July 2018 Volume LIII Number 4

Behind the Code
ICD-10-CM New Diagnosis Codes on the Horizon
 
     Diagnosis codes, also referred to as ICD codes, are used to docu- ment the reason for a patient’s visit or treatment. These codes are always required when submitting medical claims. Historically, dental payers have not required diagnosis codes for the adjudication of dental claims. Changes to our health care system have resulted in a growing trend of requiring diagnosis codes in addition to procedure codes.
 
Some of these changes include:
•Dental payers may require surgical extractions be filed with the
patient’s medical payer before submission to the dental payer.
•Pediatric dental benefits may be embedded in the medical plan, which is especially true for Affordable Care Act (ACA) plans.
•Medicare Advantage plans often have basic dental benefits em- bedded in the medical plan.
•Medical payers are increasingly providing benefits for some
medically-related dental procedures.
•Some state Medicaid and ACA plans now require diagnoses
codes for the adjudication of dental  claims.
•There is an increasing trend toward dental payers requiring diag- noses codes on dental claims.
•Some prescription plans require a diagnosis code to fill a pre- scription.
 
     When reporting diagnosis codes, it is critical that the most specific current code is reported. ICD-10-CM is the current diagnosis code set. Each year, ICD is reviewed and revised, like dental (CDT) and medical (CPT) codes. Unlike other code sets, which are effective for a calendar year (Jan. 1, to Dec. 31), ICD codes are effective for a fiscal year of Oct. 1, to Sept. 30, of each year. Therefore, the 2018 fiscal year (FY) ICD-10 code changes are effective starting Oct. 1, 2017.
     
     In June 2017, Centers for Medicaid and Medicare Services (CMS) released the ICD-10 code update for FY 2018. The complete update is available for download (free of charge) at https://www.cms.gov/Medi- care/Coding/IC018-ICD-10-CM-and-GEMs.html.
 
     Because the implementation of ICD-10 was delayed for several years and revisions to the previous code set were halted, there were approximately 2,700 additions, deletions and revisions to FY 2017 ICD-10. This year, there are significantly fewer changes. FY 2018 ICD-10 features 363 new codes, 142 deletions and more than 250 code revisions.
 
CODES FOR DENTAL CARIES RISK FACTORS
     Previously, there were no diagnosis codes available to report spe- cific oral health risk factors. However, the FY 2018 ICD-10-CM code set includes a new category for oral health risk factors. In this category are classifications for dental caries risk factors.
 
The new codes are:
•Z91.8 Other specified personal risk factors, not elsewhere classi- fied
•Z91.84 Oral health risk factors
•Z91.841 Risk for dental caries, low
•Z91.842 Risk for dental caries, moderate
•Z91.843 Risk for dental caries, high
•Z91.849 Unspecified risk for dental caries
 
     At this time, CMS has not issued specific guidelines for these codes. There are, however, general guidelines for reporting "Z" codes. These codes are found in chapter 21 of the ICD-10-CM listing, entitled "Factors Influencing Health Status and Contact with Health Ser- vices." The chapter guidelines for reporting "Z" codes state, in part, "Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed or secondary code, depending on the circumstances of the encounter." For example, an oral evaluation primarily for the purpose of determining the risk for dental caries would be reported with the appropriate risk code as the primary diagnosis.
 
     Sometimes, an oral health risk factor is the result of a primary disease process. For example, Sjogren’s syndrome increases the risk of tooth decay and oral infections. If the primary reason for the visit is treatment due to symptoms related to Sjogren’s, the ICD-10-CM code reporting the condition is listed as primary, and caries risk is listed second. It is important to note the level of risk in the clinical notes.
 
     The codes below would be reported for a patient documented with a diagnosis of Sjogren’s and a high risk of dental caries:
•M35.00 Sicca syndrome, unspecified
•Z91.843 Risk for dental caries, high
  
REVISIONS TO WORDING OF NICOTINE DEPENDENCE
 
     Some revisions are not to the code itself, rather additional information has been added to guide the provider in the use of a code. One example of this is found in category F17 (nico- tine dependence). This category is further divided based on the type of tobacco product (i.e., cigarettes, chewing tobacco, or other tobacco product). ICD-10-CM for FY 2018 now has additional clarification on the application of  these codes.
 
When reporting codes F17.201-F17.291 the following conditions apply:
 
F17 Nicotine dependence 
   F17.20 Nicotine dependence, unspecified
F17.201 Nicotine dependence, unspecified, in remission
Tobacco use disorder, mild, in early remission
Tobacco use disorder, mild, in sustained remission
Tobacco use disorder, moderate, in early remission
Tobacco use disorder, moderate, in sustained remission
Tobacco use disorder, severe, in early remission
Tobacco use disorder, severe, in sustained remission
   F17.21 Nicotine dependence, cigarettes
F17.211 Nicotine dependence, cigarettes, in remission
Tobacco use disorder, cigarettes, mild, in early remission
Tobacco use disorder, cigarettes, mild, in sustained remission
Tobacco use disorder, cigarettes, moderate, in early remission
Tobacco use disorder, cigarettes, moderate, in sustained remission
Tobacco use disorder, cigarettes, severe, in early remission
Tobacco use disorder, cigarettes, severe, in sustained remission
   F17.22 Nicotine dependence, chewing tobacco
F17.221 Nicotine dependence, chewing tobacco, in remission
Tobacco use disorder, chewing tobacco, mild, in early remission
Tobacco use disorder, chewing tobacco, mild, in sustained remission
Tobacco use disorder, chewing tobacco, moderate, in early remission
Tobacco use disorder, chewing tobacco, moderate, in sustained remission
Tobacco use disorder, chewing tobacco, severe, in early remission
Tobacco use disorder, chewing tobacco, severe, in sustained remission
   F17.29 Nicotine dependence, other tobacco product
F17.291 Nicotine dependence, other tobacco product, in remission
Tobacco use disorder, other tobacco product, mild, in early remission
Tobacco use disorder, other tobacco product, mild, in sustained remission
Tobacco use disorder, other tobacco product, moderate, in early remission
Tobacco use disorder, other tobacco product, moderate, in sustained remission
Tobacco use disorder, other tobacco product, severe, in early remission
Tobacco use disorder, other tobacco product, severe, in sustained remission
 
     Keep in mind, only diagnosed conditions that are documented in the clinical record may be reported. It is important that the patient’s condition is accurately noted in the medical record. Furthermore, reporting diagnoses codes does not guarantee reimbursement by either medical or dental payers. Always report the most specific ICD-10-CM code available to accurately describe the patient’s condition or the disease process treated.
 
     For more information, please contact AAPD Dental Benefits Director Mary Essling at messling@aapd.org or (312) 337-2169, ext. 36.
 

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