Use Combo Codes Correctly to Maximize Revenue

The ICD-10-CM Official Guidelines for Coding and Reporting defines “combination code” as a single code used to classify one of the following:

• Two diagnoses

• A diagnosis with an associated secondary process (manifestation)

• A diagnosis with an associated complication

Combination codes are hardly a new concept for provider organizations, but the inception of the ICD-10 coding system upped the ante, introducing more codes that provide increasing levels of specificity of acuity. As if that’s not complicated enough, the guidelines for how to use combo codes keep changing, says Julie Seaman, CCS, CCS-P, coding and CDI director for eCatalyst Healthcare Solutions.

“At first, the expectation was that documentation had to reflect that two conditions were related,” she says. “Then the guidelines changed, saying they didn’t have to be related.”

New for 2020, combo codes will have to be identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List.

Pick the wrong combo code that doesn’t reflect the patient’s actual level of acuity or, worse, use two codes when one combo code is applicable, and provider organizations could miss out on revenue they’re owed.

“It absolutely can affect reimbursement, both on the inpatient and outpatient side, when meeting medical necessity, for ancillary testing and in chronic care management,” she says. “With risk-adjusted payments, if physicians aren’t using the highest level of specificity, they won’t get their highest possible risk-adjusted payment. There’s a lot of money to be lost in this.”

Seaman points to one example of a miscoded inpatient stay for acute pyelonephritis. The patient had end-stage renal disease (ESRD) but the hospital failed to use the correct combo code that reflected the severity of the kidney disease—and missed out on $4,000.

Failing to use combo codes correctly can also affect continuity of care and impact patient satisfaction. “Patients with more than one chronic condition might have multiple specialists they see,” she says. “When the documentation gets passed to the next specialist in the line of care, and it wasn’t coded to the highest level of specificity, then that next physician might not pick up on something.”

Ideally, front-line clinicians are using the combo codes correctly as they’re visiting with patients—diabetes with neuropathy (E11.40) or diabetes with retinopathy (E11.319), for example. But faced with such an overwhelming list of options in the EHR, “usually they just go with the first one, which probably isn’t the right one,” Seaman says.

Realistically, then, it’s the coding department’s job to be tuned into instances where combo codes apply and take a deep dive into the documentation to understand if the combo code is applicable.

On Thursday, Oct. 24, Seaman will be co-presenting the HealthTechS3 webinar, “Chronic Care Management Coding: How to Deal With Combo Codes and the Impact on Revenue.” The webinar will cover combo code basics, knowing when to apply them and when un-coupling a combo code is the right move. She’ll also clue in participants to the most commonly used combo codes (a cheat sheet, if you will).

Seaman says while the onus of combo codes is largely on the coding department, she is starting to see a shift at provider organizations.

“It’s rare, but I have seen these edits start to happen on the front-end,” she says. “Physicians and front-line clinicians are starting to put these codes together the right way the first time.”

Register for Seaman’s webinar today.