1. Revisiting ICD-10 May 21, 2016

2. ICD-10 at a glance More codes Longer codes –up to 7 alpha/numeric Injury codes are grouped by anatomical site (rather than the category of injury). More divisions (21 chapters). Higher specificity; distinguishes between: Right and left Initial encounter, subsequent encounter, sequela ↑coding specificity for statistical analysis & research.

3. Is there an easy equivalence map between 9 and 10? NO one-to-one match. But there is a “crosswalk” – http://www.nber.org/gem/GEMs- CrosswalksBasicFAQ.pdf BEWARE: “ In coding individual claims, it will be more efficient and accurate to work from the medical record documentation and then select the appropriate code(s) from the coding book or encoder system.” “The GEMs are not a substitute for learning how to use the ICD-10-CM.”

4. ICD Linkage to CPT ICD codes form a crucial partnership with CPT procedural codes. The ICD codes indicate the reason why the CPT procedure or service was performed. ICD codes can also indicate what level CPT was performed and why. Diagnosis to procedure edits are among the most common type of edits applied to claims. The selection of the primary diagnosis for a patient encounter is usually “the reason the physician saw the patient that day” and is not necessarily the patient’s most serious condition

5. Basic Coding Principles It is important that you are coding based upon what you have documented in your patient’s records Code by subluxation first as mandated (ie. Medicare) Symptoms and ill-defined conditions can be used but only in the absence of a definitive primary diagnosis

6. Basis Coding Principles cont… Injuries: When coding an injury, reference the condition, not just the anatomical site. Choose specific diagnoses: Avoid codes for diagnoses that include the words not otherwise specified or not elsewhere classified (unless it is your only choice until more conclusive test results are received) Select codes to their highest level of specificity Non-relevant conditions: Do not code conditions which are not related to the current reason for the patient encounter

7. Coding Co-Morbidities Providers tend not to include Co-morbidities in the diagnoses. However, if it can have a direct relation to the patient’s progress and/or if it can “explain” the choice of care for the patient, then it should be documented in the patient’s chart and can be included as a diagnosis (depending on the carrier). Ie. Obesity, Diabetes, and Hypertension are just a few examples of co-morbidities/complicating factors that can have an affect on treatment

8. Updating/Changing your DX New Conditions/New Injury Change in condition Improvement Exacerbation It all goes back to documentation Don’t forget to change your illness date! (side note: Medicare says the illness date is the first date of the patient encounter)

9. ICD-10 Chapters: Chiropractic 1. Infectious 12. Diseases of Skin 2. Neoplasms Tissue13. Disease of Musculoskeletal & Connective 3. Blood and Blood-forming14. Disease of Genitourinary 4. Endocrine, Nutritional15. Pregnancy 5. Mental Disorders 16. Perinatal 6. Diseases of Nervous system17. Congenital 7. Diseases of the Eye18. Symptoms, Signs & Abnormal Clinical & Lab 8. Diseases of the Ear19. Injury and Poisoning 9. Diseases of Circulatory20. External Causes of Morbidity 10. Diseases of Respiratory 21. Factors Influencing Health Status 11. Diseases of Digestive

10. ICD-10 Layout and Definitions Includes and Excludes -Includes: gives definitions and examples

11. ICD-10 Layout and Definitions -Excludes 1: “not coded here” (when two conditions cannot occur together).

12. ICD-10 Layout and Definitions -Excludes 2: condition not included here (need additional code if documentations supports it). Code also: two codes may be required to fully describe a condition.

13. Non-essential modifiers [ ] Brackets enclose alternative wording or explanatory phrases. ( ) extra words present/absent that do not affect the code number.

14. Non-essential modifiers AND : Either “and” or “or” Example: A18.0 Tuberculosis of bones and joints. With: “associated with” or “due to”

15. ICD-10 Layout and Definitions X = place holder When the 7thcharacter is needed, but there is no 6thcharacter, an X is used as a placeholder. M48.8X1 Other specified spondylopathies, occipito-atlanto-axial region

16. Signs and Symptoms (Chapter 18) Codes that describe signs and symptoms are acceptable for reporting IF a definitive diagnosis has not been established (confirmed). Only use signs and symptoms if no definitive Diagnosis is established

17. Signs and Symptoms (S & S) Don’t use S & S if: they are routinely associated with a disease. Do use S&S if: not routinely with a disease process. Example: Person comes in with Brachial Neuritis. To include a diagnosis of shoulder pain would be redundant.

18. Uncertain Diagnosis Code to the highest degree of certainty for that encounter/visit. Do NOT use a diagnosis without certainty/documentation. Do not code: “probable” “suspected” “questionable” “rule out” “working diagnosis”

19. Etiology (cause)/ Manifestation Underlying condition –sequenced first Manifestation second Example: Parkinson’s disease (G20) with dementia F02.80 or F02.81

20. Acute and Chronic Acute conditions get listed before chronic –if both are present.

21. Code all documented conditions that coexist 1) Code all documented conditions that require or affect patient care treatment or management. 2) Do not code conditions that were previously treated and no longer exist. 3) History codes (categories Z80-Z87) may be used if it impacts current care or influences treatment. Examples: Z89.61 Acquired absence of leg above knee Z82.62 Family history of osteoporosis Z82.69 Family history of other diseases of the musculoskeletal system and connective tissue

22. M codes (Chapter 13) “M” prefix –diseases of musculoskeletal or connective. Diseases related to: Bone Joint Muscle

24. Example: Patient with Sciatica & LB Pain Find the GEM Read your exclusions Code specific to documentation The more specific – the more you increase the necessity for service

25. Laterality Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate characters (2 separate diagnosis) for both the left and right side. … 0 unspecified … 1 right … 2 left If the side is not identified in the medical record, assign the code for the unspecified side.

26. Example: 724.4 Cervical Radiculitis Find the GEM Read your exclusions Code specific to documentation Note that for this one, it is specific to a level and not a side

27. MUST have documentation! USE the most specific code that is SUPPORTED by your documentation. More changes to the diagnosis LEGALLY responsible for EVERYTHING on the bill-on paper or electronically.

28. Injury “S” Codes (Chapter 19) Strains and Sprains S00-S09 Injuries to the head S10-S19 Injuries to the neck S20-S29 Injuries to the thorax S30-S39 Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals S40-S49 Injuries to the shoulder and upper arm S50-S59 Injuries to the elbow and forearm S60-S69 Injuries to the wrist, hand and fingers S70-S79 Injuries to the hip and thigh S80-S89 Injuries to the knee and lower leg S90-S99 Injuries to the ankle and foot For most of these blocks, the third character is the one that designates the type of injury. The "3" is for sprains, while the "6" or "9" is for strains

29. Strains and Sprains It will help to remember the following information when searching for Strains vs. Sprains: A strain is an injury found under muscle/tendon/fascia A sprain is an injury found under dislocation/ligament/joint

30. ICD 10 for Lumbar Strain Search for strain of the lumbar spine. Remember a STRAIN is a muscle, fascia and tendon S- Injury, poisoning and certain other consequences of external causes S3- Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals S39- Other and unspecified injuries of the abdomen, lower back, pelvis and external genitals S39.0- Injury of muscle, fascia and tendon of the abdomen, lower back and pelvis S39.01- Strain of muscle, fascia and tendon of the abdomen, lower back and pelvis S39.012_ Strain of muscle, fascia and tendon of lower back S39.012A Strain of muscle, fascia and tendon of lower back, initial encounter

31. ICD 10 for Cervical Sprain Take a look at a sprain of the neck. It should be clearly documented as a sprain of the ligaments of the cervical spine in order to assign the correct code. Remember a SPRAIN is found under dislocation/ligament/joint S- Injury, poisoning and certain other consequences of external causes S1- Injuries to the neck S13- Dislocation and sprain of joints and ligaments at neck level S13.4- Sprain of ligaments of cervical spine S13.4xxA Sprain of ligaments of cervical spine, initial encounter This code does not have a fifth or sixth character, so we are instructed to drop in a couple of "x" placeholders. Also, do not confuse the “A” -Initial Encounter for the Initial Visit. The initial encounter should be used during the entire time the patient is receiving active treatment for the condition.

32. 7 th Character – A, D, S Medicare States: A Active Care D Subsequent – Routine Care S Sequela – Late Effect This is not a universal rule yet! You may find other payers who will want to see “A” used for the first visit and “D” used for subsequent (not routine) – it’s always best to ask the payer!

33. 7 th character - A, D, S 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.

34. HCFA Notes for ICD 10 Decimal Point should not be showing up in your diagnosis on your claim Punctuation should never show up on a claim form Your DX box should show a {0} indicating you are reporting with ICD 10

35. Additional Notes… If you find that your ICD 10 claims are being rejected check the following Did you use a valid ICD 10 code? Did you add characters that should not have been added? Did you use a non specific code? If all looks good on your end, call the Payer They may have changed their policies and what may have once been considered a covered code, may no longer be so

36. Physician Quality Reporting System aka: PQRS

37. Physician Quality Reporting System The Physician Quality Reporting System (PQRS) is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. 2015 brought a major change to PQRS There are no incentive to participate other than the avoidance of payment cuts. If you haven’t been reporting – start now!

38. Physician Quality Reporting System In the past, it has been stated that failure to participate in PQRS would result in fee cuts That day is here If you haven’t been participating in PQRS, your claims are already being cut

39. Physician Quality Reporting System Check your Medicare Fee Schedule In particular if you are a Non Participating Provider Limiting Charge EHR Limiting Charge PQRS Limiting Charge EHR & PQRS Limiting Charge

40. Physician Quality Reporting System Starting in 2017, all physicians that participate in Fee-for-Service Medicare will be affected by the Value Based Modifier Failure to have participated in PQRS in 2015 will result in the doctor being assigned the lowest level Value-Based Modifier in 2017

41. Physician Quality Reporting System Chiropractors are listed as eligible professionals We have two measures that we can report Measure #131 Pain Assessment and Follow-Up Measure #182 Functional Outcome Assessment

42. Physician Quality Reporting System Measures consist of two major components A denominator that describes the eligible cases for a measure (the eligible patient population associated with a measure’s numerator) A numerator that describes the clinical action required by the measure for reporting and performance Each component is defined by specific codes described in each measure specification along with reporting instructions and use of modifiers

43. Physician Quality Reporting System Quality-Data Codes (QDC’s) QDC’s are non-payable Healthcare Common Procedure Coding System (HCPCS) codes comprised of specified CPT Category II codes and/or G- codes that describe the clinical action required by a measure’s numerator Clinical actions can apply to more than one condition, and therefore, can also apply to more than one measure

44. Physician Quality Reporting System There is no enrollment required to report PQRS measures There are three ways to report PQRS measures Direct reporting on claim forms Reporting through a Qualified Registry Reporting through EHR

45. Physician Quality Reporting System Unfortunately none of the measures that can be reported through EHR are measures that chiropractors can report Also, currently there is no Qualified Registry that applies to chiropractic

46. Physician Quality Reporting System The satisfactory reporting requirements are: Report at least 3 measures, OR, If less than 3 measures apply to the eligible professional, report 1 -2 measures; AND Report each measure for at least 50 percent of the eligible professional’s Medicare Part B Fee For Service (FFS) patients seen during the reporting period to which the measure applies

47. Physician Quality Reporting System Measures with a 0 percent performance rate will not be counted The reporting period is January 1, 2016 to December 31, 2016. Beginning in 2015 Measure #317 (Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented) No longer needs to be reported

48. Physician Quality Reporting System Measure #131: Pain Assessment and Follow-Up. This measure documents the use of standardized pain assessment tools This is different from standardized outcomes assessment questionnaires

49. PQRS Measure #131 This measure identifies the percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

50. PQRS Measure #131 This measure is to be reported for each visit occurring during the reporting period for patients seen during the reporting period There is no diagnosis associated with this measure

51. PQRS Measure #131 This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding

52. PQRS Measure #131 The documented follow up plan must be related to the presence of pain For example: “Patient referred to pain management specialist for back pain” “Return in two weeks for re-assessment of pain”

53. PQRS Measure #131 For chiropractors the following is suggested: “Patient will be evaluated at the next visit to determine the effect of treatment on their current pain level”

54. PQRS Measure #131 CPT codes and patient demographics are used to identify patients who are included in the measure’s denominator G-codes are used to report the numerator of the measure When reporting the measure via claims, submit the listed CPT codes, and the appropriate numerator G-code

55. PQRS Measure #131 Pain Assessment – Documentation of a clinical assessment for the presence or absence of pain using a standardized tool is required. A multi-dimensional clinical assessment of pain using a standardized tool may include characteristics of pain; such as: location, intensity, description, and onset/duration.

56. PQRS Measure #131 Standardized Tool – An assessment tool that has been appropriately normalized and validated for the population in which it is used Examples of tools for pain assessment, include, but are not limited to: Brief Pain Inventory (BPI) Faces Pain Scale (FPS) McGill Pain Questionnaire (MPQ) Multidimensional Pain Inventory (MPI) Neuropathic Pain Scale (NPS) Numeric Rating Scale (NRS)

57. PQRS Measure #131 Further examples of tools for Pain Assessment: Oswestry Disability Index (ODI) Roland Morris Disability Questionnaire (RMDQ) Verbal Descriptor Scale (VDS) Verbal Numeric Rating Scale (VNRS) Visual Analog Scale (VAS)

58. PQRS Measure #131 Follow-Up Plan – A documented outline of care for a positive pain assessment is required. This must include a planned follow-up appointment or a referral, a notification to other care providers as applicable OR indicate the initial treatment plan is still in effect. These plans may include pharmacologic and/or educational interventions.

59. PQRS Measure #131 Not Eligible – A patient is not eligible if one or more of the following reason(s) exists: Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example, cases where pain cannot be accurately assessed through use of nationally recognized standardized pain assessment tools Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status

60. PQRS Measure #131 NUMERATOR NOTE: The standardized tool used to assess the patient’s pain must be documented in the medical record (exception: A provider may use a fraction such as 5/10 for Numeric Rating Scale without documenting this actual tool name when assessing pain for intensity)

61. PQRS Measure #131 For chiropractors, the denominator is one of the codes 98940, 98941, or 98942 This is to be reported on all patient encounters for patients aged 18 years and over

62. PQRS Measure #131 The numerators are in groups of two You choose which group is appropriate Then choose one of the two options with the group Numerator Quality Data Coding Options for Reporting Satisfactorily: G8730: Pain assessment documented as positive utilizing a standardized tool AND a follow-up plan is documented. OR G8731: Pain assessment documented as negative, no follow-up plan required

63. PQRS Measure #131 G8442: Pain assessment NOT documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool. OR G8939: Pain assessment documented as positive, follow-up plan not documented, documentation the patient not eligible

64. PQRS Measure #131 G8732: No documentation of pain assessment, reason not given OR G8509: Pain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given.

65. Physician Quality Reporting System Measure #182 Functional Outcome Assessment This measure documents the use of standardized outcome assessment questionnaires

66. PQRS Measure #182 Percentage of patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.

67. PQRS Measure #182 This measure is to be reported each visit for patients seen during the 12 month reporting period The functional outcome assessment is required to be current as defined in the definition section This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding

68. PQRS Measure #182 NOTE: A functional outcome assessment is multi-dimensional and quantifies pain and neuromusculoskeletal capacity; therefore theuse of a standardized tool assessing pain alone, such as the visual analog scale (VAS), does not meet the criteria of a functional outcome assessment standardized tool.

69. PQRS Measure #182 The intent of the measure is for the functional outcome assessment tool to be utilized at a minimum of every 30 days but reporting is required each visit due to coding limitations Therefore, for visits occurring within 30 days of a previously documented functional outcome assessment, the numerator quality- data code G8942 should be used for reporting purposes

70. PQRS Measure #182 Standardized Tool – An assessment tool that has been appropriately normalized and validated Examples of tools for functional outcome assessment include, but are not limited to: Oswestry Disability Index (ODI) Roland Morris Disability/Activity Questionnaire (RM) Neck Disability Index (NDI) Patient-Reported Outcomes Measurement Information System (PROMIS) Disabilities of the Arm, Shoulder, and Hand (DASH) Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL)

71. PQRS Measure #182 Functional Outcome Assessment – Patient completed questionnaires designed to measure a patient’s physical limitations in performing the usual human tasks of living and to directly quantify functional and behavioral symptoms

72. PQRS Measure #182 Current (Functional Outcome Assessment) – A patient having a documented functional assessment utilizing a standardized tool and a care plan if indicated within the previous 30 days

73. PQRS Measure #182 Functional Outcome Deficiencies – Impairment or loss of physical function related to musculoskeletal/neuromusculoskeletal capacity, may include but are not limited to: restricted flexion, extension, and rotation, back pain, neck pain, pain in the joints of the arms or legs, and headaches.

74. PQRS Measure #182 Care Plan – A care plan is an ordered assembly of expected/planned activities or actionable elements based on identified deficiencies. These may include observations, goals, services, appointments, and procedures, usually organized in phases or sessions, which have the objective of organizing and managing health care activity for the patient, often focused on one or more of the patient’s health care problems. Care plans may also be known as a treatment plan.

75. PQRS Measure #182 Not Eligible – A patient is not eligible if the following reason(s) is documented: Patient refuses to participate Patient unable to complete questionnaire Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status

76. PQRS Measure #182 CPT codes and patient demographics are used to identify patients that are included in the measure’s denominator Quality-data codes (G-codes) are used to report the numerator of the measure When reporting the measure via claims, submit the listed CPT codes, and the appropriate numerator Quality-data code

77. PQRS Measure #182 For chiropractors, the denominator is one of the codes 98940, 98941, or 98942 This is to be reported on all patient encounters for patients aged 18 years and over

78. PQRS Measure #182 The numerators are in groups You choose which group is appropriate Then choose one of the options from within the group Numerator Quality-Data Coding Options for Reporting Satisfactorily are:

79. PQRS Measure #182 G8539: Functional outcome assessment documented as positive using a standardized tool AND a care plan based on identified deficiencies on the date of the functional outcome assessment, is documented. OR G8542: Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required. OR G8942: Functional outcome assessment using a standardized tool is documented tool is documented within the previous 30 days and care plan, based on identified deficiencies on the date of the functional outcome assessment, is documented

80. PQRS Measure #182 G8540: Functional Outcome Assessment NOT documented as being performed, documentation the patient is not eligible for a functional outcome assessment using a standardized tool. OR G9227: Functional Outcome Assessment documented, care plan not documented, documentation the patient is not eligible for a care plan

81. PQRS Measure #182 G8541: Functional Outcome Assessment using a standardized tool not documented, reason not given. OR G8543: Documentation of a positive functional outcome assessment using a standardized tool; care plan not documented, reason not given.

82. PQRS Measure #182 Functional Timeline At the initial assessment visit you administer an outcome assessment questionnaire and find a functional deficiency From this you develop a treatment plan You would use G8539 for that visit

83. PQRS Measure #182 For the next 30 days you follow the treatment plan with treatment visits You would use G8942 for each of these visits

84. PQRS Measure #182 At the end of the 30 days you would re-evaluate the patient at an assessment visit You would administer another outcome assessment questionnaire, find functional deficiencies and develop a new treatment plan You would use G8539 for this visit

85. PQRS Measure #182 Standardized Outcome Assessments, questionnaires or tools are a vital part of evidence-based practice. Despite the recognition of the importance of outcome assessments, questionnaires, and tools, recent evidence suggests their use in clinical practice is limited

86. PQRS Measure #182 Selecting the most appropriate outcomes assessment, questionnaire or tool enhances clinical practice by: (1) identifying and quantifying body function and structure limitations (2) formulating the evaluation, diagnosis, and prognosis (3) informing the plan of care; and (4) helping to evaluate the success of chiropractic therapy interventions

87. Physician Quality Reporting System Both measure #131 and #182 specifically list the Oswestry Disability Index (which is another name for the Oswestry Low Back Disability Index) and the Roland Morris Questionnaire as acceptable standardized tools You may be able to use the following to satisfy some of the requirements for both measure #131 and #182 Revised Oswestry Low Back Pain Disability Index Questionnaire Neck Disability Index Rowland-Morris Questionnaire

88. Physician Quality Reporting System These measures #131 and #182 are to be reported when you file your claim It is important to place an entry in the charge field. $.01 is recommended. It won’t be paid. Do: report measures on Medicare “AT” patients Don’t: report measure on Medicare replacement policies

89. Physician Quality Reporting System By participating in the PQRS you will avoid a 2% cut in your fees starting in 2017 You will also be establishing your Value Based Modifier (VBM) The VBM will be effective for chiropractors in 2017 and will be based on your 2015 PQRS participation

90. Physician Quality Reporting System Not all of the G-codes are payable codes You should watch for a code N365 on the remittance advisories N365 reads: “This procedure code is not payable. It is for reporting/information purposes only.” This code will indicate that the reporting code passed into the national database

91. Summary of PQRS Reporting the PQRS measures is essential for two reasons To ensure that you are paid the maximum amount available from Medicare To build as accurate of a performance database as possible for chiropractic procedures and for yourself Accurately reporting the PQRS measures will prove beneficial to both you and the profession