ICD-10 codes are used to inform medical schemes about what conditions their members were treated for by healthcare practitioner so that claims can be settled correctly. The Council for Medical Schemes (CMS) is a statutory body providing regulatory supervision of private health financing through medical schemes. The CMS has noticed that healthcare professionals experience challenges in coding, and advise on the following areas of concern.
Some medical schemes informed certain healthcare professionals that some ICD-10 codes are reserved for use on accounts by specific practice types and may thus not be used by other professionals.
No ICD-10 code may be allocated or ‘reserved’ for a specific healthcare discipline or practice. Any healthcare professional who renders a service within his/her scope of practice may use any of the clinically correct ICD-10 code(s) indicated on the 2014 ICD-10 Master
Industry Table (MIT) as Valid_ICD-10_Clinical Use and Valid_ICD-10_Primary.
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 incorrect payment of benefits.
As per the National Health Act (NHA), all medical practitioners are required to complete the discharge summary which reflects the patient’s diagnoses, treatments and health education provided on discharge. Furthermore, proper documentation of patient health records, which must be available to all clinical staff involved in the treatment of a patient, is a legal requirement as per the Health Professionals Act no. 56 of 1974.
Medical and allied health professionals continue requesting ICD- 10 codes from case managers in hospitals, call centres at medical schemes and other entities, who may not do so as it is out of their scope of practice to diagnose a patient and provide ICD-10 codes.
Several healthcare professionals have indicated that certain medical schemes require their codes to match that of the hospitals. The ICD-10 codes for different healthcare professionals treating a patient within the same episode of care can differ and claims may not be rejected where codes between claims do not match.
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.
All diagnosing professionals to add the diagnosis and if possible the ICD-10 code to each medication item on a prescription. Pharmacists may not make a medical diagnosis and assign ICD-10 codes to a claim hence members of medical schemes experience severe
difficulty in having their scripts funded correctly if a default ICD-10 code is used by pharmacists.
It was reported that accounts are amended by healthcare professionals who are unable to/refuse to adhere to the secondary coding rules. They also refuse to add an External Cause Code (ECC) in the secondary 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.
Healthcare professionals should take special note of the fact that changing the ICD-10 code to a code that is not a true reflection of the member’s condition hinders quality health data collection and is fraudulent, leading to incorrect identification of PMB conditions. This may result in non-payment or incorrect payment of accounts.
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.
The CMS further noticed that healthcare providers often inform the member that a condition is included in the PMB regulations when it is not. The CMS advises healthcare providers to ensure that they provide the correct information to members and do not ‘upcode’ in order to ensure that schemes will fund a claim as a PMB. As per the PMB Code of Conduct medical schemes are entitled to request all clinical records including pathology and radiology reports to ensure that a PMB condition is correctly identified.