Category Archives: Billing

Top Ten ICD9 to ICD10 Transition Myths and Facts

ICD9 to ICD10 Transition Myths and Facts

1. Myth- I do not have to worry about the transition as it has been delayed 3 times already. Fact- HHS has no plans to extend the compliance date for implementation of ICD-10-CM/PCS; therefore, covered entities should plan to complete the steps required to implement ICD-10-CM/PCS on October 1, 2015.

2. Myth – I can use ICD10 now. Fact-The date of service determines the use of ICD9 or ICD10. Any services delivered on October 1 or later use ICD10. If the date of service was in September, regardless if the claim is sent in October or later will require ICD9.

3. Myth-The changes also involve procedure coding. Fact- There are no changes or updates to CPT coding, ICD10 only updates diagnoses for outpatient settings. There is a procedure coding system in ICD9 and one in ICD10 however those are only used in hospital inpatient settings. ICD-10-PCS will only be used for facility reporting of hospital inpatient procedures and will not affect the use of CPT.

4. Myth- The ICD10 system will require claims have an external cause of injury code with all injury claims. Fact- Use of external causes of injury for ICD10 will not be required. There has never been a reporting requirement for external causes of injury, which is also a part of ICD9, unless there is a state mandate for reporting. For example in ICD9 there are codes that describe how an injury occurred, for instance E812.0 is a driver of an automobile involved in an accident with another vehicle. However, the description of the accident does not indicate any information pertaining the actual diagnosis or necessity of care as a result of the injury. In simple terms an automobile insurance carrier does not need a code that describes it was a car accident, as they know that already, but what is actually wrong with the person such as sprain, strain, neuritis, disc, etc.

5. Myth- Doctors of chiropractic will now be required to use potentially thousands of codes. Fact- There are indeed thousands of codes, ICD9 has over 13,000 and ICD10 has 68,000 but of those thousands a doctor of chiropractic generally uses no more than 50 ICD9 codes on a regular basis, and in fact 15-20 commonly. There will be more codes with ICD10 as they are more descriptive including left, right, disc region, spine region etc. however will likely be approximately three times as many. For instance Medicare in states that require a secondary neuromusculoskeletal diagnosis generally publish about 60-70 codes, for ICD9, that a chiropractor may bill and be paid for. These list in ICD10 are about 160-200 codes.

6. Myth- Workers’ compensation and auto insurance will not use ICD10 as they are non covered entities. Fact- Because ICD-9-CM will no longer be maintained after ICD-10-CM/PCS is implemented, it is in non-covered entities’ best interest to use the new coding system. The increased detail in ICD-10-CM/PCS is of significant value to non-covered entities. The Centers for Medicare & Medicaid Services (CMS) will work with non-covered entities to encourage their use of ICD-10-CM. Special Note –However, this is why the HJ Ross Digital Coding Manual will maintain a crossover between ICD9 and ICD10 that a provider can easily move and map forward or when necessary backward and have at their disposal both codes when necessary.

7. Myth- The increased number of codes in ICD-10-CM will make the new coding system impossible to use. Fact- Just as an increase in the number of words in a dictionary doesn’t make it more difficult to use, the greater number of codes in ICD-10-CM doesn’t necessarily make it more complex to use. In fact, the greater numbers of codes in ICD-10-CM make it easier for you to find the right code. For instance ICD10 makes a distinction between myalgia M79.1 and fibromyalgia M79.7 which ICD9 does not. 722.4 in ICD9 is disc degeneration but in ICD10 M50.31 is disc degeneration from C2-3 and C3-4, M50.32 C4-5, C5-6, and C6-7 and M50.33 is C7-T1. Clearly ICD10 has much more specificity and can indicate medical necessity more succinctly simply by the specificity of the ICD10 coding which should lead to fewer requests for information from the insurance carriers.

8. Myth- Unnecessarily detailed medical record documentation will be required when ICD-10-CM is implemented. Fact- As with ICD-9-CM, ICD-10-CM codes should be based on medical record documentation. While documentation supporting accurate and specific codes will result in higher-quality data, nonspecific codes are still available for use when documentation doesn’t support a higher level of specificity. As demonstrated by the American Hospital Association/American Health Information Management Association field testing study, much of the detail contained in ICD-10-CM is already in medical record documentation, but is not currently needed for ICD-9-CM coding.

9. Myth- ICD-10-CM-based super bills will be too long or too complex to be of much use. Fact- Practices may continue to create super bills that contain the most common Diagnosis Codes used in their practice. ICD-10-CM-based super bills will not necessarily be longer or more complex than ICD-9-CM-based super bills. Neither currently-used super bills nor ICD-10-CM-based super bills provide all possible code options for many conditions.

10. Myth- Medically unnecessary diagnostic tests will need to be performed to assign an ICD-10-CM code. Fact- As with ICD-9-CM, ICD-10-CM codes are derived from documentation in the medical record. Therefore, if a diagnosis has not yet been established, you should code the condition to its highest degree of certainty (which may be a sign or symptom) when using either coding systems. In fact, ICD-10-CM contains many more codes for signs and symptoms than ICD-9-CM, and it is better designed for use in ambulatory encounters when definitive diagnoses are often not yet known.

Current Procedural Terminology (CPT)

Sometimes we get asked the difference between diagnostic (ICD) and CPT codes. Both codes sets are used to standardize medical communications across the board, but ICD codes focus on the diagnosis, whereas CPT coding identifies the services provided. Understanding how to properly use CPT codes is really critical in helping achieve prosperous reimbursement because insurance companies use these codes to determine how much a chiropractor will be paid. The CPT section in Digital Coding is a very useful tool in helping not only select, but really understand the appropriate code to use. Digital Coding has four specific chiropractic CPT sections: evaluation and management; physical medicine and rehabilitation; x-ray, and chiropractic manipulation. Did you know that misuse of a CPT code is the #1 trigger of an audit by an insurance company? All the more reason to make sure you are using the right code, the most updated code, and are knowledgeable how to apply CPT to a chiropractic practice.

The ICD-10 Transition for Chiropractic: Feet Dragging is the Norm

If you are still on the fence about ICD-10 coming to pass this October 1, 2015; you're in great company. Workgroup for Electronic Data Interchange finds that in a survey of over 1,100 physician players and vendors the biggest obstacle to industry readiness is the assumption that another delay will occur. In fact, we at Digital Coding were on the fence not too long ago also. With year-after-year of constant delays we don't blame anyone for dragging their feet on installing a transition plan. After carefully following lobbying efforts monitoring what the "big guys" such as medicare and the AMA are up-to, it seems that there is no longer enthusiasm for another delay, but rather a readiness for the transition to finally take place. Our friends at MedPage report that Barbie Hays, coding and compliance strategist for the American Association of Family Physicians says that "At this point it would need a presidential mandate for this to stop and I don't think that is going to happen." We certainly agree, and our own billing expert Sam Collins cautions to not wait until the last minute to devise your plan. The time is now to start looking at the new codes and getting your chiropractic practice in shape for the transition.

ICD-10 Coding of Strain and Sprains and Proper use of A, D and S extensions

The coding for strains and sprains is more specific in ICD10 as there are separate codes for strains and sprains while ICD9 uses one code to designate strain or sprain.

For instance for cervical spine, 847.0 is used in ICD9 to indicate a strain and sprain while ICD10 has separate codes for each. The base code for cervical strain is S13.4 and cervical sprain is S16.1. However, to be complete the codes have to be to 7 characters in length with the 7th character and A, D, or S.

Therefore the specific codes are as follows;
S13.4XXA sprain of cervical spine, initial encounter
S13.4XXD sprain of cervical spine, subsequent encounter
S13.4XXS sprain of cervical spine, sequelae
S16.1XXA strain of cervical spine, initial encounter
S16.1XXD strain of cervical spine, subsequent encounter
S16.1XXS strain of cervical spine, sequelae

At first glance it may appear obvious and logical when you identify the coding in this format is that the initial encounter is for the first visit and subsequent encounter is for the second and “subsequent” visits. However, that assumption is incorrect and without a full understanding of the definitions of the A and D extensions may lead to improper coding.

The term “initial encounter” is somewhat misleading as it actually refers to the period of time when the patient is receiving active treatment for the condition. Chiropractic treatment (physical medicine services et al) are considered active treatment as there is “active care” for the condition. Therefore the A extension S13.4XXA for cervical sprain and S16.1XXA would be the code to use for all visits when the patient is under active care.

Subsequent encounter is the visit(s) after the active phase of treatment. For instance a medical provider refers a patient to a chiropractor for care and once care is completed with the chiropractor and the patient is being “checked” out by the medical provider that would be the subsequent encounter.

The source of these definitions ICD10 CM Documentation A How-To Guide for Coders, Physicians and HealthCare Facilities 2014 pages 341- 342 Chapter 19.

Medicare Local Coverage Determination LCD for chiropractic, specifically Noridian, lists the strain and sprain codes for spine with only the A extension, as it refers to care that is active therapy (think AT modifier for CMT as required by Medicare). Use of codes with a D extension is not payable by Noridian Medicare and this diagnosis indicates the patient is not under active (corrective care).

National Government Services another multistate Medicare intermediary also lists only the strain and sprain codes with the A extensions as well but also codes with the S extension for sequelae. Sequela refers to the complications or conditions that arise as a direct result of an injury (residual effects). This residual effect can be pain, scar tissue, loss of range of motion etc. Generally sequelae code such as S13.4XXS is coded secondary to the sequelae itself. For instance residual pain in the cervical spine following a sprain would be coded in this manner.

M54.2 cervical pain as primary and S13.4XXS indicating the pain is the sequelae of a cervical sprain.

While it is the provider’s duty to choose the most appropriate code the provider must also have a correct understanding of the code meanings. For strain and sprain codes in ICD10 the A extension does indicate initial encounter but is also for all dates of service when there is active care. Therefore the most likely code a chiropractic provider would use, unless the care is no longer active, corrective, or acute would be the A extension.

Ask the Expert: Medicare

Question: Do Chiropractors Have to Bill Medicare?

Answer: According to the Medicare billing guide (sections 40 thru 40.4); the answer is a resounding Yes. Medicare requires all physicians who have not opted out of Medicare must bill for covered services provided to a Medicare patient, on the behalf of the patient. Even a non par provider not accepting assignment must submit the claim to Medicare on behalf of the patient. It also says that Chiropractors are not qualified as physicians who can opt out of Medicare. So, yes, you have to bill for covered services.

Now let's define covered services. Covered services are defined as those services listed in your Medicare LCD, or Medicare Chiropractic Billing Guide, as being covered by Medicare and are medically necessary. For chiropractic this is 98940, 98941 and 98942, for the time being. Therefore spinal manipulation must be billed to Medicare by the doctor of chiropractic. Any codes other than the three spinal manipulation codes are excluded from being covered when provided by a chiropractor, i.e. exams, x-rays, extraspinal adjustments etc. and are not required to be billed to Medicare unless there is a secondary payer to Medicare who will cover those services.

ASK THE EXPERT: Replacing Modifier 59

QUESTION? What's with the new modifiers that replace modifier 59? Will they allow me to be paid for 97140, manual therapy, when done with chiropractic manipulation?

ANSWER:Yes, there are 4 new modifiers for 2015 that are to replace and more clearly identify subsets of modifier 59. The effective date is January 1, 2015 with an implementation date January 5, 2015. Modifier 59 is used to indicate a “distinct procedural service” and these new modifiers further delineate the distinct nature of the service.

XE Separate Encounter: A service that is distinct because it occurred during a separate encounter
XS Separate Structure: A service that is distinct because it was performed on a separate organ/structure
XP Separate Practitioner: A service that is distinct because it was performed by a different practitioner
XU Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service

Currently, the use the -59 modifier is to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. Because it can be so broadly applied, some providers incorrectly consider it to be the “modifier to use to bypass National Correct Coding Initiative (NCCI)”; it is the most widely used modifier. It is also associated with considerable abuse and high levels of manual audit activity, leading to reviews, appeals and even civil fraud and abuse cases.
Modifier 59 has been prominent in chiropractic since the update of CPT code, 97250 myofascial release, to 97140 manual therapy in 1999. As I am sure you are aware manual therapy 97140, to be separately reimbursed from chiropractic manipulation must be performed to a region not being manipulated on the same visit. Regardless of the type of manual therapy when done in same region as chiropractic manipulation the services are considered bundled into the manipulation service.

Often however providers will bill 97140 with modifier 59 when the services were not performed on separate anatomic region allowing improper reimbursement for the 97140 service. Aetna indicated improper use of 59 following their investigative audits where they found that 90 percent of the time that modifier 59 was used; manual therapy was performed in the same region as the CMT. They also found very poor or lack of documentation where no specificity was indicated to establish protocol for separate reimbursement. As a consequence Aetna began to not pay for 97140 with chiropractic manipulation regardless of the modifier use. However, they did relent to some extent and began to pay chiropractors for 97140 services when additional documentation was supplied to not only include use of modifier 59 but that medical necessity and separate regions were established in the medical record. This of course required considerably more work by the provider by requiring additional clinical information on the service.

For instance under certain circumstances, it may be appropriate to additionally report CMT codes in addition to code 97140. For example, a patient has severe injuries from an auto accident with a neck injury that contraindicates CMT in the neck region. Therefore, the provider performs manual therapy techniques as described by code 97140 to the neck region and CMT to the lumbar region. As separate body regions are addressed, it would be appropriate in this instance to report both codes 97140 and 98940. In this example, the modifier -XS should be appended to indicate that a distinct procedural service was provided to a separate anatomical site.

CMS will continue to recognize the -59 modifier, but note per the instructions of Current Procedural Terminology (CPT) state that the -59 modifier should not be used when a more descriptive modifier is available. These codes will replace the use of modifier 59 where applicable. The use of 59 will likely result in greater audits, denials and requests for information for payment and therefore better to use the more detailed X(EPSU) modifier when appropriate.
This is particularly helpful considering the reimbursement policies of Aetna and United Health Care (Optum Health) which both specifically audit and request details for use of the 59 modifier when used with chiropractic manipulation with manual therapy.

How to Properly Bill for Flexion Distraction

I am very confused as to how to code the use of flexion-distraction. I have always billed it as traction but just recently heard that coding it in that manner was incorrect. What is the code that should be used for this type of service?

The coding of this service is often confused and misunderstood. I think mainly because of the term used to describe it “flexion-distraction”. Once we see that language it is common to think traction and bill it under the codes for traction. However, that is an incorrect assumption.
The coding for flexion-distraction is in fact chiropractic manipulation. Chiropractic manipulation 98940-98942 can be broadly organized into various styles of manipulation and mobilization. The best description of Flexion-Distraction technique using existing Current Procedural Terminology language and codes would be the CMT codes, 98940, 98941, or 98942. As described by Dr. Cox, an originator and arguably the technique’s name sake “Cox Flexion-Distraction” it is a method of chiropractic manipulation that uses a long axial forces.

While many chiropractors may indeed use this method as an additional source of treatment to their own chiropractic technique and see it as more a method of “traction” than a manipulation, it is manipulation none the less. The coding for this service in this manner is also substantiated by the statement and interpretation from the American Chiropractic Association (ACA), which too indicates flexion distraction, is to be coded under chiropractic manipulative therapy codes.
Per the ACA “Flexion distraction is a Chiropractic Manipulative Technique. Per the preamble of the CMT code set (98940-98943) it is a procedure that is a form of manual treatment to influence joint and neurophysiological function. The physician work included in CMT codes was laid out in a work value survey of the chiropractic profession conducted in the spring of 1996 and included the work of flexion distraction. The procedure is taught in the curriculum in accredited chiropractic programs and institutions. Therefore, the appropriate coding for this technique is 98940, 98941, or 98942, depending on the number of other body regions treated”.

Therefore if billing for traction under this code and your file was audited and noted that the service being billed under traction was indeed flexion-distraction there could be request for a refund as that service under flexion distraction was part of another service, namely and assuming 98940-98942 was billed that date of service. If no manipulation code was billed it may still be refuted as the incorrect code for the service provided, however manipulation is generally a higher valued service and no net refund may be necessary.