Category Archives: Diagnostic Coding

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.

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.

Denial of E&M Code with Chiropractic Manipulation

Examination denials

I had a denial for the examination (99203) of brand new patient. On the EOB it stated that “the service billed is included in another procedure billed the same day.” I do not understand this denial as I am required to do an exam to determine the condition of my patient and formulate a treatment plan. I did perform an chiropractic treatment in the same visit, but that code was for my specific manipulation service. Are they right, do I not get paid for an exam when I bill it with treatment? If not, what did I do wrong and how can I get my examination paid?

You are correct in that you must perform an examination to determine the patient’s condition and course of care plan. But a common error when billing for an examination the same day as treatment is to not include the modifier -25 on the exam code (in this case 99203-25). This modifier is certification that a significant, separately identifiable evaluation and management service (examination) was performed the same day.

The reason this modifier must be applied is that all chiropractic manipulation codes have an included component that is a pre-service, intra-service and post-service, assessment. This assessment is for the typical short history and evaluation done on each visit, prior to and after the day’s treatment. This assessment is not intended as the more extensive evaluation done on the first visit and re-examinations. It is for this reason that an examination (evaluation and management code) is not to be billed on every visit.

To correct this claim you must resubmit the billing with the proper modifier (25) so it will be separately reimbursed. Including a copy of the examination with the re-billing is also useful, as will avoid further delays should the insurance want to view the record of the separate examination.