DMEPOS suppliers should continue to look to the referring physicians for the ICD 10 diagnosis. However, physicians have been granted a 12-month flexibility period in which they do not have to submit diagnoses codes to the highest level of specificity. The physicians’ claims need only have a code with the correct family of diagnosis codes. DMEPOS are not allowed the same grace period. DMEPOS suppliers must bill with an ICD-10 code to the highest level of specificity. You need to submit your claims with the highest level of specificity.
If a code requires 7 characters in order to be valid, then all seven characters must be on the claim for that diagnosis code. Many of the ICD 10 codes for prosthetic treatment have a seventh character. This character may be A, initial encounter, D, subsequent encounter or S, sequela. While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time. Here is the definition of the seventh character codes directly from ICD-10-CM Official Guidelines for Coding and Reporting. (The information begins on page 65 of this document.)
7th character “A”, initial encounter is used while the patient is receiving active treatment for the condition.
7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase
7th character “S”, sequela, is for use for complications or conditions that arise as a direct result of a condition.
The following MLN Matters article may assist you with that verification: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1421.pdf.
The question of how to use the 7th character to code an initial encounter versus a subsequent encounter is the subject of a free webinar offered by the AHA Coding Clinic. Although the webinar was offered in March of 2015, if you register for the webinar, you can view the presentation. To access this webinar go to www.ahacentraloffice.org and click on the webinars tab at the top of the page. There is also a wealth of information available if you click on the coding clinic tab on this page that you may find to be helpful.