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What the CMS doesn't tell you about translating ICD-9 codes to ICD-10

The Centers for Medicare and Medicaid publish a free kit for translating ICD-9 codes to ICD-10 (and vice versa). It's called GEMS (for General Equivalence Mappings). But what the CMS doesn't tell you is that GEMS takes a relatively non-specific code set (ICD-9) and translates it into an equally non-specific set of ICD-10 codes. That defeats the whole purpose of ICD-10! Let me give you an example of what I'm talking about. Consider ICD-9 code 896.2. It's formal description is: Traumatic amputation of foot (complete) (partial): bilateral, without mention of complication GEMS would have you translate this as a pair of...

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There has to be an ICD-10 code for that

From around the Internet : A pedestrian hit me and went under my car. An invisible car came out of nowhere, stuck my car and vanished. As I approached the intersection a sign appeared in a place where no stop sign had ever appeared before. I was unable to stop in time to avoid the accident. Coming home I drove into the wrong house and collided with a tree I don't have. I collided with a stationary truck coming the other way. I had been driving for 40 years when I fell asleep at the wheel and had an accident....

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What is a CCI edit, and why should I care?

CCI (or, more formally, NCCI) stands for "National Correct Coding Initiative." This is a project of the CMS (Centers for Medicare and Medicaid) intended to clarify the rules for what procedures can be billed together on the same claim. Although its scope has expanded a bit, it helps identify "bundled" procedures. One procedure is considered "bundled" in another procedure if paying for that other one includes payment for the "bundled" one.  Attempting to bill for the "bundled" procedure results in a denial due to an "unbundling error." Some NCCI edits put other constraints on reporting two procedures on the same claim,...

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How to look up an LCD for a procedure using the CMS website

Instructions for looking up an LCD (Local Coverage Determination) for a specific procedure: Visit http://www.cms.gov/medicare-coverage-database/ In the right sidebar, click to select "Local Coverage Documents" Select the area you are interested in using the "Select Area" drop-down Enter the procedure code in the box labelled "Enter CPT/HCPCS Code" Click on the red "SEARCH BY TYPE" button Scroll to the bottom of the results page to see the LCD title(s) Click on the red "+" to show a secondary list Click on the blue link under the "LCD ID" heading Congratulations!  You now should be viewing the LCD. Of course, you could just...

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What is an LCD, and why should I even care?

"LCD" stands for "Local Coverage Determination." It is a document written for the locality covered by the Medicare contractor that services that region. Among other things, it explains what the procedure is and the conditions that will satisfy the contractor's medical necessity requirements. More specifically, it tells you which diagnosis codes must be linked with the procedure for the claim to be reimbursed. What if my claim isn't for Medicare?  Well, most private insurance carriers start out with the Medicare LCD's, and modify them to their taste. So while they are not required to follow the Medicare contractor's rules, the...

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