ICD-10 Boot Camp. Objectives 5/29/2015. Association of New Jersey Chiropractors

Transcription

1 ICD-10 Boot Camp On Behalf of: Association of New Jersey Chiropractors Presented by: David Klein CPC, CHC, 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 DISCLAIMER & TERMS THIS PRESENTATION WAS CREATED IN ORDER TO HELP HEALTH CARE PROFESSIONALS, MEDICAL BILLING PERSONNEL, CODERS AND OTHER SUPPORT PERSONNEL TO BETTER UNDERSTAND THE RAPIDLY CHANGING MEDICAL/HEALTHCARE ENVIRONMENT. DOCUMENTATION, BILLING AND CODING DECISIONS SHOULD NOT BE SOLEY BASED UPON INFORMATION CONTAINED IN THIS PRESENTATION. INDIVIDUAL CIRCUMSTANCES, LEGAL AND ETHICAL CONSIDERATIONS AS WELL AS PAYER POLICIES SHOULD ALWAYS BE CONSIDERED WHEN DETERMINING A PARTICULAR COURSE OF ACTION. THIS PRESENTATION AND CONTENTS HERIN SHALL NOT BE CONSTRUED AS LEGAL ADVICE NOR AS ESTABLISHING A CLIENT-ATTORNEY RELATIONSHIP. RESOURCES ARE PROVIDED FOR EDUCATIONAL AND AWARENESS PURPOSES ONLY, AND AS SUCH, ARE PROVIDED STRICTLY AS SAMPLES. IF YOU HAVE QUESTIONS OF A LEGAL NATURE, YOU SHOULD CONTACT AN ATTORNEY AT LAW. THE PRESENTER MAKES NO WARRANTIES, EXPRESS OR IMPLIED, REGARDING ANY SUCH RESOURCES 1

2 Telling the Story: It s not Just Documentation that tells the Story Everything we do in Practice Tells a Story, for example: Cervical Sprain/Strain indicates whiplash injury Level 1 established Exam indicates a problem that will self resolve -59 modifier indicates separate site/organ system was treated Our fee schedule reflects how we value our skills There Is Way Too Much Mis-Information The Code Definitions -- CPT-4 and ICD-9 became Federal Law as a result of the HIPAA Transactions Rule in See 45 CFR (a), I. Make sure you are using accurate sources: AMA CPT Codebook -- Current Procedural Terminology (CPT) AMA CPT Assistant -- Analogous to Advisory Opinions by a governmental entity CMS / AMA Documentation Guidelines on E/M Services (1995 or 1997) Medicare LCD s M 42 CFR : Plan of treatment requirements for outpatient rehabilitation services. II. Know What Your Provider Agreements Say: Delegation of Services to Unlicensed Personnel Clinical Policy Bulletins Appeal Processes Fee Schedules Active vs. Passive Care 2

3 ICD-10 Delay "CMS estimates that a one year delay could cost between $1 billion to $6.6 billion." That hefty price tag does not include the costs already incurred by healthcare providers, vendors and other organizations who have been preparing for ICD-10 for the last several years. However, the costs of delaying ICD-10 are not just monetary. We also need to consider: Lost momentum: Those who have been ramping up and preparing will have to hold off again. It seems probable that procrastinators will continue to hope for additional delays and will continue to avoid ICD- 10 preparation even with a longer time frame. Frozen code sets: ICD-9-CM has been frozen for several years now. This leads to problems of adequately reporting changes and data comparison on a global scale. These changes leave many unanswered questions. Watch for further announcements by professional organizations as well as the Department of Health and Human Services (HHS) who has yet to make an official statement regarding this new piece of legislation. 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 o Too much work has already been done to turn back now o The old system won t work with new technologies o That would penalize innovators o It is necessary for health care reform Recommended Tools You could also use the complete code set (~68,000 codes), available from multiple publishers 3

4 ChiroCode Complete and Easy ICD-10 Coding for Chiropractic Pages 1-43: Complete guide to understanding ICD-10-CM coding Pages 44-56: Commonly Used Codes* Pages : Code Map (GEMs)* Pages : Tabular list (abridged) Pages : Alphabetic Index* Pages : Coding Guidelines *We ll discuss these at length later What is ICD-10? 1) International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for diagnosis coding, and; 2) International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) for inpatient hospital procedure coding. What is ICD-10? The differences between ICD-9 and ICD-10 are significant: ICD-9-CM diagnosis codes, 3-5 digits 14,000 total ICD-10-CM diagnosis codes, 3-7 digits 68, 000 total ICD-9-CM procedure codes, 3-4 numbers, 4000 total ICD-10-PCS procedure codes, 7 characters, and 87,000 4

5 Drawbacks of 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 Benefits of ICD-10 More clinically relevant than ICD-9-CM Better reflection of clinical severity and complexity More accurate representation of provider performance Less ambiguous code choices Support for medical necessity Validation for reported evaluation and management codes More accurate and fair reimbursement Less misinterpretation by auditors, attorneys, other 3rd parties Benefits of ICD-10 Potentially Improved efficiencies and lowered administrative costs Fewer rejected and improper reimbursement claims Decreased demand for submission of medical record documentation Increased use of automated tools to facilitate the coding process Fewer coding errors Increased productivity Reduced labor costs 5

6 Benefits of ICD-10 Greater specificity can be achieved because the codes are: o alphanumeric o up to seven characters long Let s Compare: ICD-9 vs. ICD-10 ICD-9 Lacks detail ICD-10-CM Very VERY VERY specific 17 chapters, almost 17,000 codes 21 chapters, almost 68,000 codes 3-5 digits, decimal a/f 3 rd digit 3-7 digits, decimal a/f 3 rd digit 1 st digit alpha (E/V) or numeric; digit 2-5 numeric Lacks laterality Limiting in ability to expand Less specific codes limit data for research Difficult to analyze data Does not support interoperability b/c it is not used by other countries 1 st digit alpha; digit 2 numeric, digit 3-7 alpha-numeric Has laterality Adaptive for future technology Specificity improves coding accuracy Details provide data for statistical analysis and research Supports exchange of health data b/t other countries 6

7 When? 1) Any electronic transaction for which a standard has been adopted must be submitted using Version 5010 on or after January 1, Electronic transactions that do not use Version 5010 are not compliant with HIPAA and will be rejected. This deadline has passed. 2) All services and discharges on or after October 1, 2013 must be coded using the ICD-10 code set. The necessary system and workflow changes need to be in place by the compliance date in order for you to send and receive the ICD-10 codes. This is Delayed now October 1, How will the New Codes Work? 3-7 characters in length each added digit adds specificity to the code. 7 th character can represent visit encounters (initial, subsequent or sequelae for injuries and external causes 7 th character is used only for certain sections (e.g. musculoskeletal, injuries and external causes of injury) Some codes will use x as a place holder for characters 4-6 when needed Tabular list layout Chapter 21 of them from A to Z Block Ranges of categories Categories 3 characters Subcategories 4 th or 5 th characters Codes 6 th or 7 th characters Note: Codes may be complete with fewer than 6 characters. Some codes only have 3. 7

8 Tabular List Chapter: 13, Diseases of the Musculoskeletal System and Connective Tissue (M00 M99) (always white font in a black box) Tabular List Block: Spondylopathies (M45 M49) (Always bold CAPS, lined above and below) Tabular list: blocks Other blocks of interest within Chapter 13 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) Note: There are actually 19 blocks in Chapter 13. Each block deals with a specific disease and associated symptoms. 8

9 Tabular List Category: Spondylosis (M47) (Always all CAPS) Tabular List Subcategories: M47.8 Other Spondylosis M47.81 Spondylosis without myelopathy or radiculopathy Codes: M Spondylosis without myelopathy or radiculopathy, cervical region CMS-1500 Claim form Approved for official use 08/05 for official instructions 9

10 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 6 th, Health plans and clearinghouses must accept the form. April 1 st, 2014 Providers must use the new form How do I know which codes to use? Follow payer guidelines for code sequencing. Diagnosis code hierarchy: 1. Neurological 2. Structural 3. Functional 4. 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! 10

11 How do I know which codes to use? Medicare LCD Diagnosis List: Short term (approximately 12 treatments) Back Pain Spasm of Muscle Moderate term (approximately 18 treatments) Enthesopathy 721 Cervical Spondylosis Sprains Moderate - Long term (approximately 24 treatments) Stenosis 353 Nerve Root and Plexus Disorders Long term (approximately 30 treatments) 722 Degeneration of intervertebral disc Sciatica 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. o 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 o U.S. has used ICD-10 since 1999 to report mortality data on death certificates 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. o Ready in 1994 o Public comments o Tested in 2003 by AHA and AHIMA o Final rule for implementation published 2009 o Postponed in 2012 o Implementation October 1, 2014 (for sure, maybe) 11

12 Knowledge Check 1. ICD-10-CM contains chapters, which are separated by body region or condition. 2. Because ICD-10 codes are alphanumeric and up to seven characters long, we are able to achieve: a. greater specificity b. Nirvana c. inner peace d. perfection 34 Knowledge Check 3. ICD-10 is currently used in which of the following countries? a. Germany b. Australia c. Great Britain d. United States 4. The National Center for Health Statistics is responsible for the Clinical Modification of ICD-10 in the United States True False 5. The implementation date for ICD-10 is October 1, 2014 True False 35 Knowledge Check 6. The last update to ICD-10 was made October 1, 2011 True False 7. ICD-10 codes start with letters and contain up to six characters True False 36 12

13 Knowledge Check 8. Many ICD-10 codes contain information about left and right anatomical regions True False 9. ICD-10 codes must have six or seven characters to be complete True False 37 How are ICD-9 and ICD-10 similar? Conventions are mostly the same 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. How are ICD-9 and ICD-10 similar? Conventions are mostly the same [ ] 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 13

14 How are ICD-9 and ICD-10 similar? 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 How are ICD-9 and ICD-10 similar? 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. 14

15 ICD-10 Conventions Excludes Excludes1 consider these codes instead (you can only use 1) (mutually exclusive) Excludes2 consider these codes in addition (you may use 2 or more) (Not included) How are ICD-9 and ICD-10 similar? 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. 15

16 Direct ICD-9-CM to ICD-10-CM Real Comparison ICD-10-CM ICD-9-CM 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 CONTRACUTRE 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 are ICD-9 and ICD-10 different? ICD-9 ICD-10 How are ICD-9 and ICD-10 different? Placeholder x character 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. 16

17 What are some ICD-10 examples? 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 Direct ICD-9-CM to ICD-10-CM Comparison ICD-9 E844.8 Sucked into a jet without damage to airplane; ground crew V97.2 ICD-10-CM Increased Specificity ICD-10 Sucked into a jet without damage to airplane; 17

18 V97.29 ICD-10-CM Increased Specificity ICD-10 Sucked into a jet without damage to airplane; luggage cart driver V97.29X ICD-10-CM Increased Specificity ICD-10 Sucked into a jet without damage to airplane; luggage cart driver; male; ICD-10-CM Increased Specificity ICD-10 V97.29XA Sucked into a jet without damage to airplane; luggage cart driver; male; under5 5 in height; 18

19 V97.29XA2 ICD-10-CM Increased Specificity ICD-10 Sucked into a jet without damage to airplane; luggage cart driver; male; under5 5 in height; slightly bald ICD-10-CM Increased Specificity ICD-10 V97.29XA2G Sucked into a jet without damage to airplane; luggage cart driver; male;under5 5 in height; slightly bald; wearing a short-sleeve shirt What are some ICD-10 examples? 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 19

20 What are some ICD-10 examples? 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, Patient with Unequal leg length The 21 in M (page 196) refers to "other acquired deformities of limbs" What are some ICD-10 examples? 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, Patient with Unequal leg length The 21 in M (page 196) refers to "other acquired deformities of limbs" The 7 adds the detail of "unequal limb length." 20

21 What are some ICD-10 examples? 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, Patient with Unequal leg length 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 21

22 What are some ICD-10 examples? 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, Patient with Unequal leg length 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 What are some ICD-10 examples? W61.43 Pecked by a turkey 22

23 What are some ICD-10 examples? Migraines (page 149) 44 choices available for migraines Documentation must include: o With or without aura o Intractable or not intractable o With or without status migrainosus o Persistent or chronic o With or without vomiting o With or without opthalmoplegic, menstrual, etc o Induced by ICD-10 training Test Your Knowledge Lets Review the Workbook on Page 2 What are some ICD-10 examples? Kissing Spine In ICD-9 (alphabetic index) Kissing Osteophyte Spine Vertebra In ICD-10 (tabular list, page 216) 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 M

24 Which guidelines do DCs need to know? General Coding Guidelines General coding guidelines (page 483) o 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. General Coding Guidelines (see appendix) Code to the highest level of specificity (i.e. up to five digits in ICD-9, seven in ICD-10) (section I.B.3) List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided. (section IV.H) 72 24

25 General Coding Guidelines o Code signs and symptoms when a related definitive diagnosis has not been established (confirmed) by the provider (section I.B.6) o mostly in ICD-9 o R00 to R99 in ICD-10 Example: R45.2 Unhappiness 73 General Coding Guidelines Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes (section I.B.7) Example: R68.84 Jaw pain would not be coded with o M26.62 temporomandibular joint arthralgia Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present. (sectioni.b.8) Example: R11.0 Nausea and o S13.4xxA Sprain of ligaments of the cervical spine 74 General Coding Guidelines Do not code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosis or other similar terms indicating uncertainty. (section IV.I) 75 25

26 General Coding Guidelines Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management. (sectioniv.k) Diabetes? Pregnancy? Cancer? 76 General Coding Guidelines o The acute condition should always be listed before the chronic condition if both are present. o Look up J01.00 Acute maxillary sinusitis, unspecified Note the Excludes2 note for J32.0 chronic maxillary sinusitis 77 General Coding Guidelines A combination code is a single code used to classify: Two diagnoses, or A diagnosis with an associated secondary process (manifestation) A diagnosis with an associated complication 78 26

27 General Coding Guidelines o If the condition is bilateral and there is no bilateral code, then you have to list the left and right code separately. o Sixth character (usually) 1=right 2=left o List unspecified if laterality is not described 79 General Coding Guidelines Placeholder x character 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 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. 80 Sequela (late effects) General Coding Guidelines Residual effect after the acute phase of an illness or injury has terminated o Example: paralysis after cerebral infarction Code first the condition being treated, and second the illness or injury that led to it. Never code the acute phase of the illness or injury with a sequela 81 27

28 82 General Coding Guidelines The seventh character (encounter): 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, (perhaps degenerative disc disease a year after a neck sprain?). Sequela code (i.e. DDD) is first, then the injury code with the S on the end. 83 General Coding Guidelines The seventh character (encounter): Which character is correct? Is the patient receiving active treatment? Is the patient in the middle of an active treatment plan? Has the patient s condition stabilized? Is the patient receiving supportive care? Is the patient in a healing or recovery phase? Is the patient being treated for a complication that is the direct result of some other condition? 84 28

29 General Coding Guidelines o 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. *Note: payers are likely to deny unspecified codes o 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 ICD-10 Guidelines for DCs 1. Conventions (appendix, section I.A) 2. General Coding Guidelines (appendix, section I.B) 3. Chapter Specific Guidelines (appendix, section 1.C) 4. The Tabular List **takes precedence (in-column instructions) 29

30 Which guidelines do DCs ICD-10 need to know? III. Tabular list 1. Infectious Diseases 2. Neoplasms 3. Blood 4. Endocrine 5. Mental 6. Nervous 7. Eye 8. Ear 9. Circulatory 10. Respiratory 11. Digestive 12. Skin 13. Musculoskeletal 14. Genitourinary 15. Pregnancy 16. Perinatal 17. Congenital malformations 18. Signs and Symptoms 19. Injuries and Poisoning 20. External Causes 21. Health Status Which guidelines do DCs 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 Which guidelines do DCs 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 30

31 Which guidelines do DCs 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 Chapter Specific Guidelines A few examples from Chapter 18 R07.1 Chest pain on breathing R07.82 Intercostal pain R10.83 Colic R11.0 Nausea R11.12 Projectile vomiting R20.1 Hypoesthesia of skin R26.2 Difficultly in walking, NEC R29.4 Clicking hip R42 Dizziness and giddiness R51 Headache R52 Pain, unspecified R60.0 Localized edema R68.84 Jaw pain R93.9 Diagnostic imaging inconclusive due to excess body fat of patient Note: Do not code from this list. Use the tabular list to determine if one of these codes is appropriate. 31

32 Which guidelines do DCs 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 Which guidelines do DCs 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 Knowledge Check 10. The first three characters in ICD-10 describe the: a. Etiology b. Payment details c. Category d. Anatomic site 11. Relevant instructional notes for a single code can be found at the level of: a. The general guidelines b. The chapter specific guidelines c. The chapter heading d. The block (code range) e. The category (three characters) f. The subcategory (four or five characters) g. The code itself h. All of the above 32

33 Knowledge Check 12. Which of the following ICD-10 conventions is used for a code that is defined in the physician documentation, but not accurately described anywhere in the tabular list? a. NOS b. Excludes1 c. NEC d. and 13. The placeholder x is optional and should be deleted before listing a code on a claim form. True False 14. When a diagnosis has not been established by the provider, it is acceptable to report codes for the presenting signs and symptoms. True False Knowledge Check 15. Code all conditions that coexist, even if they are not addressed or do not affect management/treatment during that encounter. True False 16. A code is invalid if it has not been reported to the full number of characters available, including the seventh character, if applicable. True False 17. The types of encounters available for the seventh character for certain ICD-10 codes include: a. new, established, former b. initial, subsequent, sequela c. acute, chronic, maintenance d. on time, late, no show Knowledge Check 18. If there is a condition that affects multiple sites, the proper way to code it is: a. Seek out a multiple sites code, and use it, if available b. Code each site separately c. Use the unspecified code 19. CMS has required that external cause codes should be assigned to every case that has an acute injury. True False 33

34 How do I find the ICD-10 code? Medicare LCD for ICD-9 Short term 306, 339, 784 Headaches 718 Contracture 721 Spondylosis Back Pain Moderate term 353 Root lesions 720 Enthesiopathy 722 Unspecified disc disorders 723 Other cervical disorders 724 Stenosis 729 Myalgia 738, 756 Spndylolisthesis Sprains Long term 721 Traumatic Spondylopathy 722 Degeneration, displaced discs 724 Sciatica Medicare LCD for ICD-10 Short term G44 Headaches M24.5 Contracture M47 Spondylosis M48 DISH M54 Dorsalgia Moderate term G54 Nerve root and plexus disorders M43 Spondylolisthesis M46 Spinal enthesiopathy M48 Spinal Stenosis M50, M51 Disc disorders M53 Other dorsopathies, NEC M54 Radiculopathies M60 Myositis M62 Spasm of back M79 Myalgia M99 Other biomechanical lesions Long term M48 Traumatic spondylopathies M50 DDD M51 Disc displacement M54 Sciatica M96 Postlaminectomy Note: These are only categories. To find the complete list, contact your CMS contractor or check the Medicare Coverage Database 34

35 How do I find the ICD-10 code? Three methods using the ChiroCode ICD-10 book: 1. Commonly used code list, pages (but don t stop there!) 2. GEMs code map, pages (don t stop here either!) 3. Alphabetic index, pages (this is not safe either!) Always confirm the code using the tabular list (pages ). How do I find the ICD-10 code? General Equivalence Mappings (GEMs) o Created by the National Center for Health Statistics, part of the CDC o Forward maps from ICD-9 to ICD-10 o Backward maps from ICD-10 to ICD-9 o Download the free tablet/smartphone app called FindACode o Use the Code Map section in the ChiroCode ICD-10 book (pages ) o ChiroCode members can access the MapACode tool in their accounts 1. Common Codes 35

36 2. GEMs 3. Alphabetic index 4. Tabular Listing

37 Example 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 pain in the low back. An x-ray reveals a grade II spondylolisthesis at L4. On September 30, 2014, the diagnosis is Acquired Spondylolisthesis. On October 1, 2014, it is: M43.16 Spondylolisthesis, lumbar region Note: Common codes gave two options GEMs was unspecified Alphabetic Index only gave the category How do I find the ICD-10 code? One-to-one mapping: Cervicalgia M54.2 Cervicalgia (Note the Excludes1 note on page 221) One-to-four mapping: Thoracic or lumbosacral neuritis (radicular syndrome of the lower limbs) M54.14, M54.15,M54.16, M54.17 Radiculopathy (How do these four codes differ?) 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) 37

38 How do I find the ICD-10 code? 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: Sciatica M54.30 Sciatica, unspecified side M54.31 Sciatica, right side M54.32 Sciatica, left side OR M54.40 Sciatica with lumbago, unspecified M54.41 Sciatica with lumbago, right side M54.42 Sciatica with lumbago, left side Knowledge Check 20. GEMs refers to mapping files that crosswalk ICD-9 to ICD-10 True False 21. All of the following are good methods for finding the correct ICD-10 code, except: a. GEMs b. A list you got from your buddy from school c. Alphabetic index d. Common codes lists from your association or other reputable source

39 Knowledge Check 22. You diagnose a patient with cervicobrachial syndrome and select the ICD-9 code A code map using GEMs says that the ICD-10 code could be: M53.1 Cervicobrachial syndrome The alphabetic index says that the ICD-10 code could be: M53.1 Cervicobrachial syndrome The tabular list confirms that the code is: M53.1 Cervicobrachial syndrome 115 Knowledge Check 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 Knowledge Check 23. Patient presents with pain, weakness, numbness, and tingling in both legs. The correct code(s) is/are: a) M54.41, M54.42 b) M54.31, M54.32 c) M54.33 d) M

40 Knowledge Check 24. 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. 118 Knowledge Check 25. 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 ) 26. 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, 2015, the diagnoses are and On October 1, 2015, it is: M54.41 Lumbago with sciatica, right side M43.16 Spondylolisthesis, lumbar region (GEMs is unspecified, confirm with tabular) 119 How do I code for a subluxation? 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. 40

41 How do I code for a subluxation? 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 How do I code for a subluxation? 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 How do I code for a subluxation? 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 41

42 How do I code for a subluxation? 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 How do I code for a subluxation? 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 How do I code for a subluxation? 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) 42

43 How do I code for a subluxation? 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 Understand sure to confirm the code selected with the tabular list. the guidelines and conventions. How do I code for whiplash? Using the Alphabetic index (sprain of spine cervical) we find: 847.0: Sprain of neck (includes strain of joint capsule, ligament, muscle, tendon) 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? 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 7 th character, or encounter (A: initial, D: subsequent, or S: sequela) 43

44 How do I code for whiplash? Sprain of neck 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. How do I code for whiplash? Sprain of neck Which code will be acceptable? Contact the payer to be sure Note the use of the placeholder x Note the seventh character How do I code for whiplash? Sprain of neck (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

45 How do I code for DDD? 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 How do I code for DDD? 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 What does the documentation look like? 45

46 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 External Causes What does the documentation look like? 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. What does the documentation look like? S06.0x1A Concussion with loss of consciousness of 30 minutes or less, initial encounter G 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 Y Place of occurrence, house, single family, kitchen 46

47 What does the documentation look like? Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident In ICD-9, the codes might be: (see workbook) 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 Test Your Knowledge Lets Review the Workbook on Page 11 What does the documentation look like? Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident In ICD-9, the codes might be: (see workbook) 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 47

48 What does the documentation look like? Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident In ICD-9, the codes might be: 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 What does the documentation look like? Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident In ICD-9, the codes might be: 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. What does the documentation look like? Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident In ICD-9, the codes might be: 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. 48

49 What does the documentation look like? Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident In ICD-9, the codes might be: 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 What does the documentation look like? 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. o Intractable means hard to control or deal with o This must be documented in order to select the correct code. What does the documentation look like? Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident In ICD-9, the codes might be: 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 49

50 What does the documentation look like? 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) What does the documentation look like? 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 What does the documentation look like? 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 50

51 What does the documentation look like? 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 What does the documentation look like? 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 What does the documentation look like? 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 51