ICD-10 Boot Camp On Behalf of: Oklahoma Chiropractors Association

ICD-10 Boot Camp On Behalf of: Oklahoma Chiropractors Association
Presented by: David Klein CPC, CHC & Evan M. Gwilliam, MBA DC CPC CCPC NCICS CCCPC CPC-I MCS-P CPMA Sponsored by:

Objectives Gain a basic understanding of ICD-10
Understand the reason for the transition Identify the similarities and differences from ICD-9 Get familiar with relevant guidelines Learn how to select the right codes Learn how to document properly Know how to implement ICD-10 Reduce ICD-10 related anxiety

Recommended Tools ChiroCode’s Complete and Easy ICD-10 Coding for Chiropractic Inside you will find: Comprehensive list of relevant ICD-10-CM codes for Chiropractic (~15,000 codes) Tools to help you convert from ICD-9-CM to ICD-10-CM GEMs code map Commonly used codes Alphabetic index Complete guide to understanding ICD-10-CM coding Other aids you need for a painless transition.

Recommended Tools You could also use the complete code set (~68,000 codes), available from multiple publishers

Disclaimer Every attempt has been made to make this presentation as current as possible, but things change Be sure to check with your local carriers and Medicare for updates as the ICD-10 implementation date gets closer Subscribe to ChiroCode alerts or follow ChiroCode on Twitter for updates that pertain to DCs

The Landscape

The Landscape Insurance coding affects 75% of these reimbursement categories

CMS-1500 Claim form Approved for official use 08/05
for official instructions

CMS-1500 Claim form Revision 02/12
Changed to match the electronic format (5010) and ICD-10 codes Adds space for eight more diagnosis codes in box 21. January 6th, Health plans and clearinghouses must accept the form. April 1st, 2014 – Providers must use the new form

Why do we have diagnosis codes?
HIPAA requirement Establish medical necessity Process claims Translate written terminology into common language Provide data for statistical analysis Identify fraud, set healthcare policy, measure quality

Where did they come from?
ICD-9 was developed by the World Health Organization for public health and statistical analysis First revision 1893, ninth revision 1979 Shifted focus from mortality to morbidity “ICD-9-CM” means Clinical Modification - for use with health care claims in the U.S. ICD-9-CM was mandated in 1988 under the Medicare Catastrophic Coverage Act, then reaffirmed by HIPAA in 1996

How do I know which codes to use?
Follow payer guidelines for code sequencing. Diagnosis code hierarchy: Neurological Structural Functional Soft tissue For example, sciatica (724.3) and DDD (722.4) will carry more weight than spasm (728.85) or myalgia (729.1) It is said that some software only looks at the first diagnosis when adjudicating a claim, so make it count!

Medicare Universal Diagnosis List: Short term (approximately 6-12 treatments) 721 Spondylosis Back Pain Moderate term (approximately12-18 treatments) 353 Root lesions 722 Unspecified disc disorders 724 Stenosis 846-7 Sprains Long term (approximately18-24 treatments) 722 Degeneration, displaced discs

Do not code the “kitchen sink”. Example: 847.0 Sprain of neck 723.4 Brachial neuritis or radiculitis NOS 739.1 Nonallopathic lesions, cervical region 728.4 Laxity of ligament (cervical) 728.85 Spasm of muscle (cervical) 729.1 Myalgia and myositis, unspecified 847.1 Sprain of thoracic 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 739.2 Nonallopathic lesions, thoracic region 728.4 Laxity of ligament (thoracic) 728.85 Spasm of muscle (thoracic) 719.7 Difficulty in walking 784.0 Headache 780.5 Sleep disturbances Laxity of ligament is for rheumatism, excluding the back, typically used from chronic conditions >30 days excludes the back too, but is included in WPS LCD, but not Noridian. 719.7 is usually chronic too. More pain while walking is not the same thing. It requires a limp. Same thing applies to Abnormality of Gait 784.0 Headache is for when the cause is unknown would have been better (acute post trauma headache) 780.5 (sleep disturbances). The patient’s difficulty sleeping is not an isolated symptom of unknown origin; it is a direct result of the pain in his upper back caused by the accident. The patient stated his neck pain makes it hard to get comfortable enough to fall asleep at night In general, don’t use codes from they are for when the origin of the problems are not known.

Are all of these codes medically indicated by the patient’s records? Are any of the rendered codes merely symptoms of other codes? Are the rendered codes as accurate and precise as possible, given the supporting medical documentation?

Why can’t we keep using ICD-9?
Too old Many sections are full and cannot be expanded Not descriptive enough Not able to accurately reflect advances in medical knowledge or technology Will not meet healthcare needs of the future

Requires excessive reliance on supporting paper documentation Hampers the ability to compare costs and outcomes

~14,000 codes ICD-10 ~68,000 codes

Will Oct. 1, 2014 be the end of the world?

Where did ICD-10 come from?
The World Health Organization issued the tenth revision of the International Classification of Disease (ICD-10) in the early 90’s. Each country is responsible for adapting ICD-10 to suit its needs Australia uses ICD-10-AM Germany uses ICD-10-GM Canada uses ICD-10-CA United States uses ICD-10-CM U.S. has used ICD-10 since 1999 to report mortality data on death certificates Show some “Yeah, there is a code for that” videos. Mention ICD-10-PCS and volume 3 of I-9 (for surgery and inpatient centers). Benefits of I-10: more codes, combination codes with diagnosis and symptoms, code extensions for injuries, placeholders (“x”), seven characters instead of five, laterality codes, twice as many categories.

Where did ICD-10 come from?
ICD-10-CM (CM=Clinical Modification) was developed by the National Center for Health Statistics for reporting morbidity and mortality in the U.S. Ready in 1994 Public comments Tested in 2003 by AHA and AHIMA Final rule for implementation published 2009 Postponed in 2012 Implementation October 1, 2014 (for sure, maybe) Show some “Yeah, there is a code for that” videos. Mention ICD-10-PCS and volume 3 of I-9 (for surgery and inpatient centers). Benefits of I-10: more codes, combination codes with diagnosis and symptoms, code extensions for injuries, placeholders (“x”), seven characters instead of five, laterality codes, twice as many categories.

Won’t they just postpose it again?

Won’t they just postpone it again?
Jan. 2013, the AMA asked CMS to abandon ICD-10 Feb. 6, 2013, CMS Acting Administrator, Marilyn Tavenner said no Too much work has already been done to turn back now The old system won’t work with new technologies That would penalize innovators It is necessary for health care reform

Won’t they just postpone it again?
ICD-10 does a better job than ICD-9 with: Providing data for statistical analysis Measuring quality and outcomes Helping to set healthcare policy Identifying public health threats Identifying fraud and errors Exchanging data among health care entities In other words, we need it to improve our health care system. But it won’t work if everyone uses unspecified codes. The increased specificity of the ICD-10 codes require more detailed clinical documentation in order to code some diag. There are “unspecified” codes in ICD-10-CM for those instances when the health record documentation is not available to support more specific codes The benefits of ICD-10 can not be realized if non-specific codes are used noses to the highest level of specificity rather than taking advantage of the specificity ICD-10 offers

How are ICD-9 and ICD-10 similar?
Still a tabular list divided into chapters based on body system or condition Similar hierarchy Still an index with main terms and sub-terms Must code to the highest level of specificity ICD-10 is mandated under HIPAA

Conventions are mostly the same (page 467) NEC “Not elsewhere classified” Used when the information in the medical record provides detail for which a specific code does not exist NOS “Not otherwise specified” or “unspecified” Used when the information in the medical record is insufficient to assign a more specific code.

Conventions are mostly the same (page 467) [ ] Brackets are used in the tabular list to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the Index to identify manifestation codes ( ) Parentheses are used in both the Index and Tabular to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers

Conventions are mostly the same “Includes” This note appears immediately under a three-digit code title to further define, clarify, or give examples of the content of a code category. “And” The word “and” should be interpreted to mean either “and” or “or” when it appears in a title… “either or” For example, a code might say “hand and forearm”. The code would cover a diagnosis that effected just the hand, just the forearm, or both.

Conventions are mostly the same “Excludes” Excludes1 – is used when two conditions cannot occur together or “NOT CODED HERE!” Mutually exclusive codes; two conditions that cannot be reported together. Excludes2 – indicates “NOT INCLUDED HERE.” Although the excluded condition is not part of the condition, it is excluded from, a patient may have both conditions at the same time. The excluded code and the code above the excludes can be used together if the documentation supports them.

Conventions are mostly the same “Code First/Use additional code” Provides instructions on how to “sequence” the codes. Signals that that an additional code should be reported to provide a more complete picture of the diagnosis. “Code Also” Alerts the coder that more than one code may be required to fully describe the condition. The sequencing of the codes depends on the severity and/or the reason for the encounter.

Official Guidelines (about 30 pages) Indexes Diseases and Injuries (300 pages) Neoplasms (20 pages) Drugs and Chemicals (30 pages) External Causes (20 pages)

Official Guidelines (about 30 pages) Indexes Diseases and Injuries (340 pages) Neoplasms (20 pages) Drugs and Chemicals (50 pages) External Causes (35 pages)

Tabular list (340 pages) Infectious Diseases Neoplasms Endocrine Blood Mental Nervous Circulatory Respiratory Digestive Genitourinary Pregnancy Skin Musculoskeletal Congenital malformations Perinatal Signs and Symptoms Injuries and Poisoning E-codes. External Causes V-codes. Health Status ICD-9

Tabular list (600 pages) Infectious Diseases Neoplasms Blood Endocrine Mental Nervous Eye Ear Circulatory Respiratory Digestive Skin Musculoskeletal Genitourinary Pregnancy Perinatal Congenital malformations Signs and Symptoms Injuries and Poisoning External Causes Health Status ICD-10

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99) page 166 M00 to M25, Arthropathies (diseases of the joints) M40 to M43, Dorsopathies (diseases of the spine) M45 to M49, Spondylopathies (diseases of the vertebrae) M50 to M54, Other Dorsopathies M60 to M63, Disorders of Muscles M65 to M67, Disorders of synovium and tendons M70 to M79, Other soft tissue disorders M80 to M94, Osteopathies and Chondropathies (diseases of bone and cartilage) M99 Biomechanical Lesions, NEC (subluxations and others) Codes assigned to each chapter are broken into blocks of one or more 3 digit codes each. Each block deals with a specific disease and associated symptoms.

How are ICD-9 and ICD-10 different?
The alphanumeric structure of ICD-10 allows for more specific information Increased codes and categories allow for more accurate representation of the patient’s diagnoses

Feature ICD-9-CM ICD-10-CM Number of Codes About 14,000 About 68,000 Number of characters 3-5 characters in length Characters are all numeric (or E or V) Decimal is used after 3 characters 3-7 characters in length Character 1 is alpha Character 2 is numeric Characters 3-7 are alpha or numeric Some codes use “x” for characters 4-6 Character 7 used in certain chapters Number of chapters 17 chapters (plus E and V) 21 chapters

Feature ICD-9-CM ICD-10-CM Start Date 1975, 1979 in US 1994, 2014 in US Expansion Very limited Has significant ability to expand without a structural change Detail Lacks detail Very specific Laterality Lacks laterality Includes laterality when appropriate Encounters Encounters are not defined Initial and subsequent encounters are defined Combination Codes Combination codes are limited Combination codes are frequent Combination codes allow easy coding of frequent co-morbidities Injury codes were grouped by category of injury in I-9, but now by anatomical site in I-10. I-10 better for statistical analysis. The transition is actually a little easier since I-10 is old. The kinks have been worked out.

Extension 7th character is for obstetrics, injuries and external causes

Explain placeholder “x” and seventh character

Placeholder “x” character (guidelines, page 466) ICD-10-CM utilizes a placeholder character “x” in positions 4, 5, and/or 6 in certain codes to allow for future expansion. 7th Characters Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder “x” must be used to fill in the empty characters. Explain placeholder “x” and seventh character

What are some ICD-10 examples?
Add info about the # of Gout codes in ICD-9 ICD-10-CM code for chronic gout due to renal impairment, left shoulder, without tophus. Note: there are 11 gout codes in ICD-9 and 365 in ICD-10

In ICD-9: E Sucked into a jet without damage to airplane; ground crew

In ICD-10: V : Sucked into a jet without damage to airplane;

In ICD-10: V : Sucked into a jet without damage to airplane; luggage cart driver

In ICD-10: V97.29& : Sucked into a jet without damage to airplane; luggage cart driver; male

In ICD-10: V97.29&A : Sucked into a jet without damage to airplane; luggage cart driver; male; under 5’5” in height;

In ICD-10: V97.29&A# : Sucked into a jet without damage to airplane; luggage cart driver; male; under 5’5” in height; slightly bald;

In ICD-10: V97.29&A#g : Sucked into a jet without damage to airplane; luggage cart driver; male; under 5’5” in height; slightly bald; wearing a tank top

In ICD-10: V97.29&A#g€: Sucked into a jet without damage to airplane; luggage cart driver; male; under 5’5” in height; slightly bald; wearing a tank top; during a full moon

V95.42xA Spacecraft crash injuring occupant, initial encounter W59.22xA Struck by a turtle, initial encounter G44.82 Headache associated with sexual activity V91.07xA Burn due to water-skis on fire, initial encounter (search for this one on FindACode.com) W22.01xD Walked into wall, subsequent encounter Y34 Unspecified event, undetermined intent R45.2 Unhappiness

M refers to "diseases of the musculoskeletal system and connective tissue." After the letter are two characters, then a decimal, then more characters which add more specific information. For example, the “21” in M (page 196) refers to "other acquired deformities of limbs" The “7” adds the detail of "unequal limb length." The “5” tells us that it is at the femur The “2” tells us that it is on the left

W Pecked by a turkey

Migraines (page 149) 44 choices available for migraines Documentation must include: With or without aura Intractable or not intractable With or without status migrainosus Persistent or chronic With or without vomiting With or without opthalmoplegic, menstrual, etc Induced by ICD-10 training G Chronic migraine without aura, not intractable, with status migrainosus

Kissing Spine In ICD-9 (alphabetic index) Kissing Osteophyte Spine Vertebra In ICD-10 (tabular list, page 217) Kissing Spine, unspecified M48.20 Occipito-atlanto region M48.21 Cervical region M48.22 Cervicothoracic region M48.23 Thoracic region M48.24 Thoracolumbar region M48.25 Lumbar region M48.26 Lumbosacral region M48.27 When looking up kissing spine in the ICD-10-CM you would look up “Kissing Spine” instead of just “Kissing” with an indent. “Kissing Spine” provides the following options. In order to select the correct code here you would not only need adequate documentation but also know that there are 24 vertebra in the body; 7 cervical (C1 – C7), 12 thoracic (T1 –T12), 5 lumbar (L1 – L5), 5 sacral (S1- S5), and 3-5 coccygeal (fused to form tailbone). In addition you would also need to know that names like cervicothoracic pertain to both the cervical and thoracic vertebra and therefore should only be used when both types of vertebra are documented as being affected.

Sixty one year old female presents to your office with ongoing right hip pain and stiffness. Patient stated she had a soft-tissue injury to her right hip six years ago following a bicycle accident. X-rays at the time negative for fracture. Tenderness to palpation in the right hip, with a positive Patrick’s test on the right reproducing the hip symptoms. X-rays of the left hip were unremarkable, however, the right hip showed sclerosis of the superior aspect of the acetabulum. DX: Post-traumatic osteoarthritis of the right hip. ICD-10: M99.06 Segmental and somatic dysfunction of lower extremity M16.51 Unilateral post-traumatic osteoarthritis, right hip

Which guidelines do DCs
need to know? General coding guidelines (page 484) ICD-10-CM codes should be listed at their highest level of specificity and characters. a. Use three digit codes only if there are no four digit codes within the coding category. These are the heading of a category of codes. b. Use the 4, 5, 6, or 7 digit code to the greatest degree of specificity available. These provide further detail.

need to know? General coding guidelines Codes that describe symptoms and signs are only acceptable if that is the highest level of diagnostic certainty documented by the doctor. No other diagnosis has been established (confirmed) by the provider. (see R00 to R99) Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Additional signs and symptoms that are not routinely associated with a disease may be reported.

Which guidelines do DCs need to know?
General coding guidelines Coding for diagnoses that are probable, suspected, likely or questionable are not to be coded, because they indicate uncertainty. They may not be used with outpatient encounters. Code all documented conditions that coexist at the time of the visit that REQUIRE OR AFFECT patient care. Do not code conditions that no longer exist.

General coding guidelines The acute condition should always be listed before the chronic condition if both are present.

General coding guidelines If the condition is bilateral and there is no bilateral code, then you have to list the left and right code separately. List unspecified if laterality is not described

General coding guidelines (page 486) An unspecified code should be reported only when it is the code that most accurately reflects what is known about the patient’s condition at the time of that particular encounter. It is inappropriate to select a specific code that is not supported by the health record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. .

need to know? Tabular list Infectious Diseases Neoplasms Blood Endocrine Mental Nervous Eye Ear Circulatory Respiratory Digestive Skin Musculoskeletal Genitourinary Pregnancy Perinatal Congenital malformations Signs and Symptoms Injuries and Poisoning External Causes Health Status ICD-10

need to know? Chapter 6: Guidelines for diseases of the nervous system (G00 – G99) (page 487) Dominant or non-dominant side in hemiplegia (G81): For ambidexterous patients, default is dominant If the left side is affected, default is non-dominant If the right side is affected, default is dominant Pain (G89 pain, not elsewhere classified) For generalized acute, chronic, post-thoracotomy, post-procedural, or neoplasm related. Localized pain codes are found in other chapters (i.e. M54.9, back pain) G89 can be the principal diagnosis when it is reason for visit

need to know? Chapter 13: Guidelines for diseases of the musculoskeletal system and connective tissue (M00 – M99) (page 490) Site & laterality Site represents the bone, muscle, or joint involved Bone conditions occurring in a joint are classified by the bone involved, not the joint If a “multiple sites” code is available, use it instead of listing several sites individually Acute traumatic versus chronic recurrent In general acute injury should be coded from chapter 19, recurrent or chronic conditions are coded from chapter 13

need to know? Chapter 18: Guidelines for symptom, signs, and abnormal clinical findings, not elsewhere classified (R00 – R99) (page 491) Use of symptom codes Acceptable when a definitive diagnosis has not been established by the provider With a definitive diagnosis Only when the symptom is not routinely associated with the diagnosis In a combination code Don’t code the symptom separately if it is part of a combination code

need to know? Chapter 19: Guidelines for injury, poisoning, and certain other consequences of external causes (S00 – T88) (page 492) The seventh character A – initial encounter, while patient is receiving active treatment such as surgery, ER, or evaluation and treatment by a new physician D – subsequent encounter, routine care during the healing or recovery phase, such as cast change, medication adjustment, aftercare and follow up S – sequela, complications or conditions that arise as a direct result of a condition, such as degenerative disc disease a year after a neck sprain. Sequela code (i.e. DDD) is first, then the injury code.

need to know? Chapter 19: Guidelines for injury, poisoning, and certain other consequences of external causes (S00 – T88) (page 492) Injuries Code most serious injury first Superficial injuries are not coded with more serious injuries at the same site (such as contusions) Primary injury is first, then code for minor injury to nerves and blood vessels Pain due to medical devices would sequenced with a T code followed by G89.18 Other acute postprocedural pain or G89.28 Other chronic postprocedural pain

need to know? Chapter 20: Guidelines for external causes of morbidity (V00 – Y99) (page 494) Never sequenced first Provide data about cause, intent, place, activity, or status of the accident or patient No national requirement to use these codes, but voluntary reporting is encouraged Y92 Place of occurrence should be listed after other codes, used only once at initial encounter, in conjunction with Y93 Y93 Activity code should be used only once, at initial encounter

How do I find the ICD-10 code?
MAPPING

Always confirm the code using the tabular list (pages 135-454).
How do I find the ICD-10 code? Three methods using the ChiroCode ICD-10 book: Commonly used code list, pages (but don’t stop there!) GEMs code map, pages (don’t stop here either!) Alphabetic index, pages (this is not safe either!) Always confirm the code using the tabular list (pages ).

General Equivalence Mappings (GEMs) Created by the National Center for Health Statistics, part of the CDC Forward maps from ICD-9 to ICD-10 Backward maps from ICD-10 to ICD-9 Download the free tablet/smartphone app called “FindACode” Use the Code Map section in the ChiroCode ICD-10 book (pages ) ChiroCode members can access the MapACode tool in their accounts

Quiz Do questions 1 through 9 in the case studies hand out.

How do I find the ICD-10 code? One-to-one mapping:
723.1 Cervicalgia  M54.2 Cervicalgia (Note the Excludes1 note on page 221) One-to-four mapping: 724.4 Thoracic or lumbosacral neuritis (radicular syndrome of the lower limbs) M54.14, M54.15,M54.16, M Radiculopathy (How do these four codes differ?) Some ICD-9-CM codes map easily to ICD-10 in a simple one-to-one conversion. For example, the ICD-9-CM code maps directly to the ICD-10-CM code M54.2. (An exact map does not always mean the codes match in detail.) Note the Excludes1 note on page cervicalgia due to disc

How do I find the ICD-10 code? One-to-many mapping:
Other disorders of bone and cartilage, nonunion of fracture  S02.91XK through S92.919K (for a total of 2530 corresponding ICD-10-CM possibilities)

Look up Sciatica in the “Code Map” section (this is using GEMs-page 83) -M54.30 Sciatica, unspecified side -unspecified codes need to be investigated Look up “sciatica” in the ICD-10 index (page 470) -M54.3 Sciatica -at least five characters required to code to the highest level of specificity Now find it in the tabular list (page 221)

How do I find the ICD-10 code? Combination mapping: 724.3 Sciatica
M54.30 Sciatica, unspecified side M54.31 Sciatica, right side M Sciatica, left side OR M54.40 Sciatica with lumbago, unspecified M54.41 Sciatica with lumbago, right side M54.42 Sciatica with lumbago, left side

How do I find the ICD-10 code? One-to-two mapping:
Spasm of muscle M62.40 Contracture of muscle, unspecified site M Other muscle spasm But is that the whole story?

How do I find the ICD-10 code? 728.85 Spasm of muscle
Look up these codes in the tabular list (page 230) and you’ll find: Spasm of muscle M62.40 Contracture Of Muscle Unspecified Site M Contracture Of Muscle Right Shoulder M Contracture Of Muscle Left Shoulder M Contracture Of Muscle Unspecified Shoulder M Contracture Of Muscle Right Upper Arm M Contracture Of Muscle Left Upper Arm M Contracture Of Muscle Unspecified Upper Arm M Contracture Of Muscle Right Forearm M Contracture Of Muscle Left Forearm M Contracture Of Muscle Unspecified Forearm M Contracture Of Muscle Right Hand M Contracture Of Muscle Left Hand M Contracture Of Muscle Unspecified Hand M Contracture Of Muscle Right Thigh M Contracture Of Muscle Left Thigh M Contracture Of Muscle Unspecified Thigh M Contracture Of Muscle Right Lower Leg M Contracture Of Muscle Left Lower Leg M Contracture Of Muscle Unspecified Leg M Contracture Of Muscle Right Ankle And Foot M Contracture Of Muscle Left Ankle And Foot M Contracture Of Muscle Unspecified Ankle And Foot M62.48 Contracture Of Muscle Other Site M62.49 Contracture Of Muscle Multiple Sites M Muscle Spasm Of Back M Muscle Spasm Of Calf M Other Muscle Spasm

How do I code for a subluxation?
739.1 Nonallopathic lesions, Not Elsewhere Classified; cervical region, cervicothoracic region Includes “Somatic and segmental dysfunction” Note: The word “subluxation” does not appear in ICD- 9-CM in the 739 codes.

739.1 Nonallopathic lesions, Not Elsewhere Classified; cervical region, cervicothoracic region Using GEMs / code map (page 96), we find: M99.01 Biomechanical lesions, Not Elsewhere Classified; segmental and somatic dysfunction of cervical region Note: Still no mention of the “subluxation”

739.1 Nonallopathic lesions, Not Elsewhere Classified; cervical region, cervicothoracic region Using the tabular list (page 252), we find: M99.11 Subluxation complex (vertebral) of cervical region Note: this code maps back to 839, not 739

739.1 Nonallopathic lesions, Not Elsewhere Classified; cervical region, cervicothoracic region Using the alphabetic index (Subluxation and dislocationcervical vertebrae) we find: S13.1_ _ _ subluxation and dislocation of cervical vertebrae Still 54 possible combinations! Note: These codes all map back to 839 codes in ICD-9 Better fit for 839 codes, but lets talk about it anyway.

Fifth character gives the specific vertebral level: S13.10_ _ Subluxation and dislocation of unspecified cervical vertebrae S13.11_ _ Subluxation and dislocation of C0/C1 cervical vertebrae S13.12_ _ Subluxation and dislocation of C1/C2 cervical vertebrae S13.13_ _ Subluxation and dislocation of C2/C3 cervical vertebrae S13.14_ _ Subluxation and dislocation of C3/C4 cervical vertebrae S13.15_ _ Subluxation and dislocation of C4/C5 cervical vertebrae S13.16_ _ Subluxation and dislocation of C5/C6 cervical vertebrae S13.17_ _ Subluxation and dislocation of C6/C7 cervical vertebrae S13.18_ _ Subluxation and dislocation of C7/T1 cervical vertebrae

Sixth character differentiates between a subluxation and a dislocation: 0= subluxation 1= dislocation S13.110_ Subluxation of C0/C1 cervical vertebrae S13.111_ Dislocation of C0/C1 cervical vertebrae

Seventh character identifies the encounter: S13.110A Subluxation of C0/C1 cervical vertebrae, initial encounter S13.110D Subluxation of C0/C1 cervical vertebrae, subsequent encounter S13.110S Subluxation of C0/C1 cervical vertebrae, sequela Seventh character extension: A= initial encounter: (i.e. active treatment - initial E/M visit) D= subsequent encounter: (i.e. healing, recovery, aftercare, or follow-up) S= sequela (complications as a result of an injury) (ex: scar due to burns) Encounter per provider or per diagnosis

739.1 Nonallopathic lesions, Not Elsewhere Classified; cervical region, cervicothoracic region All of these options are listed in the “Commonly Used Codes for Chiropractic” (page 44) for the cervical region. Be sure to confirm the code selected with the tabular list. Understand the guidelines and conventions.

How do I code for whiplash? 847.0: Sprain of neck
(includes strain of joint capsule, ligament, muscle, tendon) Using the Alphabetic index (sprain ofspinecervical) we find: S13.4_ _ _ Sprain of ligaments of the cervical spine Note that there must be seven characters for the code to be complete. (See page 279)

How do I code for whiplash? 847.0 Sprain of neck
Using GEMs / code map (page 124) we find: S13.4xxA Sprain of ligaments of the cervical spine S13.8xxA Sprain of joints and ligaments of other parts of the neck This represents six possible codes, depending on the 7th character, or encounter (A: initial, D: subsequent, or S: sequela)

S13.4xxA specifies the anterior longitudinal ligament, atlanto-axial joints, atlanto-occipital joints, and whiplash injury S13.8xxA just says “other parts of the neck” Documentation should match these descriptions.

Which code will be acceptable? Contact the payer to be sure Note the use of the placeholder “x” Note the seventh character Add S16 strain codes

(includes strain of joint capsule, ligament, muscle, tendon) Using the Alphabetic index (injury ofmuscle, fascia and tendon atneck level) we find: S16.1xxA Strain of muscle, fascia and tendon at neck level, initial encounter Note: S16.1xxA maps backward to 847.0

722.4 Degeneration of a cervical intervertebral disc
How do I code for DDD? 722.4 Degeneration of a cervical intervertebral disc Using GEMs / code map, we find: M50.30 Other cervical disc degeneration, unspecified cervical region Unspecified codes should be avoided, if possible According to GEMs

722.4 Degeneration of a cervical intervertebral disc
How do I code for DDD? 722.4 Degeneration of a cervical intervertebral disc On our own (page 219), we find: M50.31 Other cervical disc degeneration, high cervical region M50.32 Other cervical disc degeneration, mid-cervical region M50.33 Other cervical disc degeneration, cervicothoracic region According to GEMs

Quiz #9 You diagnose a patient with cervicobrachial syndrome and select the ICD-9 code A code map using GEMs (pages ) says that the ICD-10 code could be: M53.1 Cervicobrachial syndrome The alphabetic index (pages ) says that the ICD-10 code could be: M53.1 Cervicobrachial syndrome The tabular list (page 206) confirms that the code is: M53.1 Cervicobrachial syndrome M53.1 no

Quiz M53.1 Cervicobrachial syndrome The fine print in the tabular list says: -Excludes2: cervical disc disorder (M50._) thoracic outlet syndrome (G54.0) This means that these diagnoses are not included in this code. If they are present, these codes should be listed as well. This information did not appear in ICD-9.

Quiz #10. Patient presents with pain, weakness, numbness, and tingling in both legs. The correct code(s) is/are: M54.41, M54.42 M54.31, M54.32 M54.5 M54.9 What method did you use to find the answer? Add the number “3” for bilateral

Quiz #11. a. In ICD-9, the code used for fibromyalgia is Myalgia and myositis, unspecified, fibromyositis NOS. Using the alphabetic index, look up the ICD-10 codes for myalgia, myositis, and fibromyositis. List them here: M79.1, M60, M79.7 (note that M60 is incomplete) b. Using GEMs, identify which codes might replace in ICD-10. M60.9 Myositis, M79.1 Myalgia, and M79.7 Fibromyalgia (note that M60.9 is unspecified, and fibromyositis has been replaced with fibromyalgia) c. Describe how you might need to change your documentation for the ICD-10 codes. 729.1 Myalgia and Myositis, unspecified points to M60.9 Myositis, M79.1 Myalgia, and M79.7 Fibromyalgia

Quiz #12. An 81 year old patient presents with spinal stenosis in the lumbar region. What is the appropriate ICD-10 code? M48.06 Spinal Stenosis, lumbar region (in index: look up “spinal”, not “stenosis”) #13. A 32 year old female presents with low back pain at L4/L5. The pain worsens with extension and with exercise. The patient complains of tight hamstrings and some numbness and pain in to the right leg. An x-ray reveals a grade II spondylolisthesis at L4. On September 30, 2014, the diagnoses are and On October 1, 2014, it is: M54.31 Sciatica, right side M43.16 Spondylolisthesis, lumbar region (GEMs is unspecified, confirm with tabular) M48.06 Spinal Stenosis, lumbar region M Spondy, lumbar. Alpha index says only M43.1, and code map says M43.10 unspecified.

What does the documentation look like?
Codes must be supported by the documentation in the patient record. The AAPC estimates an increase in documentation time of 15%. The AAPC also found that 65% of physician notes were not specific enough. Examples of details not necessary in ICD-9: side of dominance trimesters stages of healing laterality ordinality

S: Mrs. Finley presents today after having a new cabinet fall on her last week, suffering a concussion, as well as some cervicalgia. She was cooking dinner at the home she shares with her husband. She did not seek treatment at that time. She states that the people that put in the cabinet in her kitchen missed the stud by about two inches. Her husband, who was home with her at the time told her she was “out cold” for about two minutes. The patient continues to have cephalgias since it happened, primarily occipital, extending up into the bilateral occipital and parietal regions. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. She denies any vision changes, any taste changes, any smell changes. The patient has a marked amount of tenderness across the superior trapezius. O: Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart rate is regular and lungs are clear. A: Status post concussion with acute persistent headaches Cervicalgia Cervical somatic dysfunction P: The plan at this time is to send her for physical therapy, three times a week for four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We’ll recheck her in one month, sooner if needed.

S06.0x1A Concussion with loss of consciousness of 30 minutes or less, initial encounter G44.311 Acute post traumatic headache, intractable M54.2 Cervicalgia M99.01 Segmental and somatic dysfunction of cervical region W20.8xxA Struck by falling object (accidentally), initial encounter Y93.G3 Activity, cooking and baking Y92.010 Place of occurrence, house, single family, kitchen

Other Activity Codes Y93.4 Activity involving dancing and other rhythmic movement (page ) Y93.41 Dancing Y93.42 Yoga Y93.43 Gymnastics Y93.44 Trampolining Y93.45 Cheerleading

“Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident” In ICD-9, the codes might be: 847.0 Cervical sprain Acute post-traumatic headache E813.0 Motor vehicle traffic accident involving collision with other vehicle; driver of motor vehicle other than motorcycle injured

“Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident” In ICD-9, the codes might be: 847.0 Cervical sprain General Equivalence Mappings (free FindACode app) suggest the following codes: S13.4xxA Sprain of ligaments of the cervical spine, initial encounter OR S13.8xxA Sprain of other parts of the neck, initial encounter Note: When you look up S13.4xxA in the tabular list, you will find which parts of the cervical spine it includes in the fine print. This is why you need a complete book, not just a short crosswalk list of codes.

“Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident” In ICD-9, the codes might be: 847.0 Cervical sprain If you knew to look up “injury of muscle, facscia and tendon atneck level” in the index you would also find: S16.1xxA Strain of muscles, fascia and tendon at neck level, initial encounter Note: Sprain and strain are separate codes in ICD-10. Crosswalks won’t tell you about this code, you need to know how to use the alphabetic index.

“Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident” In ICD-9, the codes might be: Acute post-traumatic headache GEMs suggest: G Acute post-traumatic headache, not intractable Note: In the index G is next to G which is the intractable version of this condition. Intractable means “hard to control or deal with” This must be documented in order to select the correct code.

“Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident” In ICD-9, the codes might be: E813.0 Motor vehicle traffic accident involving collision with other vehicle; driver of motor vehicle other than motorcycle injured Note: External cause codes describe location, circumstances, and causes of injury. More detail is needed since these codes are greatly expanded in ICD-10. (However, they are only required if you already use ICD-9 E-codes)

“Exam findings are consistent with strain and sprain of the ligaments and muscles of the cervical spine and acute traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with another motor vehicle on the interstate. He was not treated at the scene.” The ICD-10 codes in this case are: S13.4xxA Sprain of ligaments of the cervical spine, initial encounter S16.1xxA Strain of muscles, fascia and tendon at neck level, initial encounter G Acute post-traumatic headache, intractable V49.40xA Driver injured in collision with unspecified motor vehicle, traffic accident, initial encounter Y Interstate as place of occurrence of the external cause

How do I implement ICD-10 in my practice?
ICD-10 Myths and Facts The date will be delayed Worker’s Comp and Auto insurance will still use ICD-9 The number of codes make ICD-10 impossible to use Documentation requirements are impractical ICD-10 is already out of date ICD-10 will replace CPT Myth Fact Myth or Fact

Which parts of a practice will be affected?
Front Desk System updates, training Providers Management Documentation with more specificity Vendor and payer contracts Budgeting New code specific training Training plan Compliance plan, coding guidelines

Which parts of a practice will be affected?
Clinical areas New patient coverage policies New super bills New LCDs Billing Code set training Reimbursement policies (more denials?)

According to CMS, 1 in 5 physician practices will see Medicare denials double within 6 months because they weren't prepared for ICD-10 by Oct. 1, 2014.

Readiness Survey: What do you already know about ICD-10? Why are we changing? How much do you think ICD-10 will affect your clinic? What specific questions would you like answered on ICD-10? Where do you plan to go for more information?

Budgeting for ICD-10 falls into four categories: Information systems upgrades Education and training Staffing and overtime costs Auditing and monitoring documentation for ICD-10 According to a RAND corporation study, it could cost as much as $40,000 on average, but small clinics may be closer to just $4,000.

Questions for your software vendors: Do I need to pay for an upgrade? Will the software have a built in crosswalk? If so, is it based only on GEMs? Will you provide any training or assistance? Will the software be able to report both ICD-9 and ICD-10 codes if necessary? When will you be ready to test your program?

Places to update your ICD-9 codes: EHR/EMR Software – allow time for updates and training. Forms – charting forms, internal forms, etc. Documents – ex. ABN form Website Contracts Policy & Procedure Manuals Inter-departmental documents

Update the list of ICD-9 codes you use most often. Create a new superbill with your specific ICD-10 mapping! Start with GEMs code maps, the common code list, and the alphabetic index, but recognize the need to dig deeper.

Medicare: free training ChiroCode.com: free alerts and webinars, more training, memberships, and chart audits, coding tools FindACode.com: Crosswalks and other advanced tools ICD10Monitor.com: free articles AAPC.com and AHIMA.org

Review the basics- go over these notes again with your whole office Buy ChiroCode Complete and Easy ICD-10 Coding for Chiropractic (or some other, less spectacular, comprehensive resource) Dedicate a few minutes of each office meeting to ICD-10 Assign someone to read ten pages from the book, then report on what they learned (only 43 intro pages). Find articles in Chiropractic trade journals and share them at each meeting. Run a report with the list of most common ICD-9 codes, then create your own crosswalk Take a real patient file and crosswalk it to ICD-10, then rework the documentation.

Use the project management steps in the book (page 37) to keep on track. You will: Plan a budget for implementation expenses Update all your forms Contact all your vendors Conduct internal testing Use ChiroCode Consulting services if you need help. Have a good time!

Is ICD-10 good…. or bad? Researchers will have better data
Physicians will need to work on documentation Billers and coders will need to get familiar with which codes are preferred by payers Payers will be able to reimburse more accurately Expect increased rejections, denials, and payment delays as both health plans and providers get used to the new codes.

Is ICD-10 good…. or bad? Recommendation: don’t procrastinate.

Quiz #14. a. Use the commonly used ICD-10-CM codes for Chiropractic section to find idiopathic thoracic scoliosis. (pages 44-56). M41.24 Other idiopathic scoliosis, thoracic region b. Now look it up in the alphabetic index (pages ) M41 Scoliosis c. Now look up in the code map section (pages ) M41.20 Other idiopathic scoliosis, site unspecified d. Now go to the tabular list. What do you need to know to choose a code that is not unspecified? Type of scoliosis (infantile, juvenile, adolescent, thoracogenic, neuromuscular, secondary), then location M41.24 in common list M41 in index M41.20 in code map

Quiz #15. Suzie Derkins reports to the office today after falling at home out of her bed. She appears to suffer from thoracolumbar radiculopathy as a result. She states that she was previously diagnosed with neuralgia. a. The coder selects M54.15 and M79.2. This is wrong. Why? Excludes1 b. Use the index to find the appropriate External Cause codes for this scenario. (hint: one describes the place of the accident and the other explains the cause of the injury) Y Bedroom of single family house (look up “place” in the index, then browse Y92) W06.xxxA Fall from bed (fall frombed) Excludes1 applies to M54.15 and M79.2. Y Index look up “place”, then search tabular list manually until you find “single family non-institutional (private) house” W06.xxxA Index look up “fall from”, then “bed”. Note placeholders.

Quiz 16. Find the ICD-10 code for Rheumatoid arthritis: M06.9 Rheumatoid arthritis, unspecified 17. Find the ICD-10 Code for pain in the neck: M54.2 Cervicalgia (look up “cervicalgia” not “neck” or “pain”) RA M06.9 Neck pain M54.2

Quiz 21. Mr. Smith presents with a sprained ankle. What questions need to be asked in order to find the complete ICD-10 code? Which ligament, which side, which encounter? S93.4_ _ _ Sprain of ankle 22. Create the proper documentation for S43.211D Anterior subluxation of right sterno-clavicular joint, subsequent encounter 23. a. Create the proper documentation for M Adolescent idiopathic scoliosis, thoracic region b. Is this code appropriate for congenital scoliosis? No, excludes1, should be Q67.5 Congenital deformity of the spine Which ligament?, which side?, which encounter? S93.4 22. Ant. Subluxation of right sterno-clavicular joint, subsequent encounter Adolescent idiopathic scoliosis, thoracic region b. No, excludes1, should be Q67.5

Quiz 24. After an MRI, Mr. Hobbes is diagnosed with L4/5 disc herniation with right-sided sciatica. How many codes are necessary? One or two? M51.16 Intervertebral disc disorders with radiculopathy, lumbar region - includes the disc and the sciatica. See excludes1 at M54.3_ Sciatica 25. Calvin complains of numbness in his right hand as well as neck pain. An x-ray reveals spondylosis all throughout the cervical spine. M Other spondylosis with radiculopathy, cervical region M54.2 Cervicalgia may be included M51.16 includes the disc and the sciatica.. See excludes1 at M54.3 M51.2 might be if they only have back pain. 25. M Other spondylosis with radiculopathy, cervical region M54.2 Cervicalgia is probably included

Procrastination

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ICD-10 Boot Camp On Behalf of: Oklahoma Chiropractors Association

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