ICD-10 coding challenges and concerns
The Health Professions Council of South Africa (HPCSA) says that the Council for Medical Schemes (CMS) has noticed that some healthcare professionals are experiencing ICD-10 coding challenges and advise on the following six areas of concern:
Allocation of certain ICD-10 codes to specific disciplines
Some medical schemes informed certain healthcare professionals that some ICD-10 codes are reserved for use on accounts by specific practice types only and may thus not be used by other professionals.
Recording of clinical information
Clinical documentation at hospitals is often insufficient for accurate coding, resulting in the assignment of sign and symptom codes and over-utilisation of default codes, which impacts negatively on health data collection and can result in the incorrect payment of benefits.
Professionals requesting ICD-10 codes from hospital case managers and call centres
A number of medical and allied health professionals continue requesting ICD- 10 codes from case managers in hospitals, call centres at medical schemes and other entities that may not do so as it is not in their scope of practice to diagnose a patient and provide ICD-10 codes.
Professionals not providing referral codes or diagnosis
Diagnosing professionals must supply the diagnosis, chief complaint and/or symptom and, where possible, ICD-10 code(s) to the non-diagnosing professionals especially pharmacists and pathologists as referral information.
Professionals changing ICD-10 codes to avoid secondary codes
It was reported that accounts are amended by some healthcare professionals who are either unable to, or who refuse to adhere to the secondary coding rules. They also fail to add an External Cause Code (ECC) in the second position (SDX) when an injury/poisoning (chapter XIX S/T code) has been coded. This results in medical schemes not being able to reimburse the member, as the provision of the ECC is compulsory with all injury/poisoning codes. Instances have been reported where the primary (PDX) ICD-10 code has been changed from an ‘S’ injury code to an ‘M’ musculoskeletal code, to avoid having to add the ECC in the secondary position.
Professionals changing ICD-10 codes to ensure PMB payment
It is of grave concern to the CMS that certain healthcare professionals change the diagnostic code to an ICD-10 code that is included in the PMB-coded list. Healthcare professionals should be aware that this is fraudulent and may lead to non-payment of claims.
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