ChiroCode s ICD-10 Boot Camp Presented by Evan M. Gwilliam, MBA DC CPC CCPC NCICS CCCPC CPC-I MCS-P CPMA Sponsored by 1 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 2 1
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 o GEMs code map o Commonly used codes o Alphabetic index Complete guide to understanding ICD-10-CM coding Other aids you need for a painless transition. 3 Recommended Tools You could also use the complete code set (~68,000 codes), available from multiple publishers 4 2
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 5 The Landscape 6 3
The Landscape 7 CMS-1500 Claim form Approved for official use 08/05 www.nucc.org for official instructions 8 4
9 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, 2014 - Health plans and clearinghouses must accept the form. April 1 st, 2014 Providers must use the new form 10 5
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 11 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 o 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 12 6
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! 13 How do I know which codes to use? Medicare Universal Diagnosis List: Short term (6-12 treatments) 721s Spondylosis 723-724s Back Pain Moderate term (12-18 treatments) 353s Root lesions 722.9s Unspecified disc disorders 724s Stenosis 846-7s Sprains Long term (18-24 treatments) 722s Degeneration, displaced discs 14 7
How do I know which codes to use? 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 15 How do I know which codes to use? 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? 16 8
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 17 Why can t we keep using ICD-9? Requires excessive reliance on supporting paper documentation Hampers the ability to compare costs and outcomes 18 9
Why can t we keep using ICD-9? ICD-9 ~14,000 codes ICD-10 ~68,000 codes 19 10
Will Oct. 1, 2014 be the end of the world? 21 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 22 11
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 1997-1998 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) 23 Won t they just postpose it again? 24 12
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 25 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. 26 13
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 27 How are ICD-9 and ICD-10 similar? 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. 28 14
How are ICD-9 and ICD-10 similar? 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 29 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 30 15
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. 31 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. 32 16
How are ICD-9 and ICD-10 similar? ICD-9 I. Official Guidelines (about 30 pages) II. Indexes i. Diseases and Injuries (300 pages) i. Neoplasms (20 pages) ii. Drugs and Chemicals (30 pages) iii. External Causes (20 pages) 33 How are ICD-9 and ICD-10 similar? ICD-10 I. Official Guidelines (about 30 pages) II. Indexes i. Diseases and Injuries (340 pages) ii. Neoplasms (20 pages) iii. Drugs and Chemicals (50 pages) iv. External Causes (35 pages) 34 17
How are ICD-9 and ICD-10 similar? ICD-9 III. Tabular list (340 pages) 1. Infectious Diseases 2. Neoplasms 3. Endocrine 4. Blood 5. Mental 6. Nervous 7. Circulatory 8. Respiratory 9. Digestive 10. Genitourinary 11. Pregnancy 12. Skin 13. Musculoskeletal 14. Congenital malformations 15. Perinatal 16. Signs and Symptoms 17. Injuries and Poisoning E-codes. External Causes V-codes. Health Status 35 How are ICD-9 and ICD-10 similar? ICD-10 III. Tabular list (600 pages) 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 36 18
How are ICD-9 and ICD-10 similar? Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00 M99) 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) 37 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 38 19
How are ICD-9 and ICD-10 different? 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 Number of chapters 17 chapters (plus E and V) 21 chapters 3-7 characters in length Character 1 is alpha Character 2 is numeric Characters 3-7 are alpha or numeric Decimal is used after 3 characters Some codes use x for characters 4-6 Character 7 used in certain chapters 39 How are ICD-9 and ICD-10 different? 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 Combination Codes Encounters are not defined Combination codes are limited Initial and subsequent encounters are defined Combination codes are frequent 40 20
How are ICD-9 and ICD-10 different? ICD-9 ICD-10 41 How are ICD-9 and ICD-10 different? 42 21
How are ICD-9 and ICD-10 different? 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. 43 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 44 22
What are some ICD-10 examples? In ICD-9: E844.8 Sucked into a jet without damage to airplane; ground crew 45 What are some ICD-10 examples? In ICD-10: V97.2 : Sucked into a jet without damage to airplane; 46 23
What are some ICD-10 examples? 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 47 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) T75.01XD: shock due to being struck by lightning, subsequent encounter Y34: Unspecified event, undetermined intent R45.2: Unhappiness 48 24
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, the 21 in M21.752 (page 183) refers to "other acquired deformities of limbs" The 7 adds the detail of "ʺunequal limb length." The 5 tells us that it is at the femur The 2 tells us that it is on the left 49 What are some ICD-10 examples? W61.43 Pecked by a turkey 50 25
What are some ICD-10 examples? Migraines (page 140) 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 G43.701 Chronic migraine without aura, not intractable, with status migrainosus 51 What are some ICD-10 examples? In the Alphabetic Index: o Kissing Spine In ICD-9 Kissing Osteophyte 721.5 Spine 721.5 Vertebra 721.5 In ICD-10 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 52 26
What are some ICD-10 examples? 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: 1. M99.06 Segmental and somatic dysfunction of lower extremity 2. M16.51 Unilateral post-traumatic osteoarthritis, right hip 53 Which guidelines do DCs need to know? General coding guidelines (page 470) 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. 54 27
Which guidelines do DCs need to know? General coding guidelines o 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) o Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. o Additional signs and symptoms that are not routinely associated with a disease may be reported. 55 Which guidelines do DCs need to know? General coding guidelines o Coding for diagnoses that are probable, suspected, likely or questionable are not to be coded, because they indicate uncertainty. o 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. 56 28
Which guidelines do DCs need to know? General coding guidelines o Coding for diagnoses that are probable, suspected, rule out, etc are not allowed for outpatients. o The acute condition should always be listed before the chronic condition if both are present. 57 Which guidelines do DCs need to know? 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 List unspecified if laterality is not described 58 29
Which guidelines do DCs need to know? General coding guidelines (page 472) 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. 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.. 59 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 60 30
Which guidelines do DCs need to know? Chapter 6: Guidelines for diseases of the nervous system (G00 G99) (page 473) 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) 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 61 Which guidelines do DCs need to know? Chapter 13: Guidelines for diseases of the musculoskeletal system and connective tissue (M00 M99) (page 476) 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 62 31
Which guidelines do DCs need to know? Chapter 18: Guidelines for symptom, signs, and abnormal clinical findings, not elsewhere classified (R00 R99) (page 477) 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 63 Which guidelines do DCs need to know? Chapter 19: Guidelines for injury, poisoning, and certain other consequences of external causes (S00 T88) (page 478) 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 scar formation after a burn. Sequela code (i.e. scar) is first, then the 64 injury code. 32
Which guidelines do DCs need to know? Chapter 19: Guidelines for injury, poisoning, and certain other consequences of external causes (S00 T88) (page 478) 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 or G89.28 65 Which guidelines do DCs need to know? Chapter 20: Guidelines for external causes of morbidity (V00 Y99) (page 480) 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 Place of occurrence = Y92, listed after other codes, used only once at initial encounter, in conjunction with Y93 Activity code = Y93, used only once, at initial encounter 66 33
How do I find the ICD-10 code? How do I find the ICD-10 code? Three methods using the ChiroCode ICD-10 book: 1. GEMs code map (but don t stop there!) 2. Alphabetic index (don t stop here either!) 3. Commonly used code list (this is not safe either!) Always confirm the code using the tabular list. 68 34
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 55-131) o ChiroCode members can access the MapACode tool in their accounts 69 How do I find the ICD-10 code? One-to-one mapping: 723.1 Cervicalgia M54.2 Cervicalgia One-to-four mapping: 724.4 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?) (page 207) 35
How do I find the ICD-10 code? One-to-many mapping: 733.82 Other disorders of bone and cartilage, nonunion of fracture S02.91XK through S92.919K (for a total of 2530 corresponding ICD-10-CM possibilities) How do I find the ICD-10 code? Look up 724.3 in the Code Map section (this is using GEMs-page 82) -M54.30 -unspecified codes need to be investigated Look up sciatica in the ICD-10 index (page 455) -M54.3 -at least five characters required to code to the highest level of specificity Now find it in the tabular list (page 207) 72 36
How do I find the ICD-10 code? Combination mapping: 724.3 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 How do I find the ICD-10 code? One-to-two mapping: 728.85 Spasm of muscle M62.40 Contracture of muscle, unspecified site M62.838 Other muscle spasm But is that the whole story? 37
How do I find the ICD-10 code? Look up these codes in the tabular list (page 215) and you ll find: 728.85 Spasm of muscle M62.40 Contracture Of Muscle Unspecified Site M62.411 Contracture Of Muscle Right Shoulder M62.412 Contracture Of Muscle Left Shoulder M62.419 Contracture Of Muscle Unspecified Shoulder M62.421 Contracture Of Muscle Right Upper Arm M62.422 Contracture Of Muscle Left Upper Arm M62.429 Contracture Of Muscle Unspecified Upper Arm M62.431 Contracture Of Muscle Right Forearm M62.432 Contracture Of Muscle Left Forearm M62.439 Contracture Of Muscle Unspecified Forearm M62.441 Contracture Of Muscle Right Hand M62.442 Contracture Of Muscle Left Hand M62.449 Contracture Of Muscle Unspecified Hand M62.451 Contracture Of Muscle Right Thigh M62.452 Contracture Of Muscle Left Thigh M62.459 Contracture Of Muscle Unspecified Thigh M62.461 Contracture Of Muscle Right Lower Leg M62.462 Contracture Of Muscle Left Lower Leg M62.469 Contracture Of Muscle Unspecified Leg M62.471 Contracture Of Muscle Right Ankle And Foot M62.472 Contracture Of Muscle Left Ankle And Foot M62.479 Contracture Of Muscle Unspecified Ankle And Foot M62.48 Contracture Of Muscle Other Site M62.49 Contracture Of Muscle Multiple Sites M62.830 Muscle Spasm Of Back M62.831 Muscle Spasm Of Calf M62.838 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. 76 38
How do I code for a subluxation? 739.1 - Nonallopathic lesions, Not Elsewhere Classified; cervical region, cervicothoracic region Using GEMs / code map (page 95), we find: M99.01: Biomechanical lesions, NEC; segmental and somatic dysfunction of cervical region Note: Still no mention of the subluxation 77 How do I code for a subluxation? 739.1 - Nonallopathic lesions, Not Elsewhere Classified; cervical region, cervicothoracic region Using the tabular list (page 238), we find: M99.11: Subluxation complex (vertebral) of cervical region Note: this code maps back to 839, not 739 78 39
How do I code for a subluxation? 739.1 - Nonallopathic lesions, Not Elsewhere Classified; cervical region, cervicothoracic region Using the alphabetic index (Subluxation and dislocation cervical vertebrae) we find: S13.100A S13.181S S13.1 _ is subluxation and dislocation of cervical vertebrae Still 54 possible combinations! Note: These codes all map back to 839 codes in ICD-9 79 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 40
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) 41
How do I code for a subluxation? 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 47) for the cervical region. Be Understand sure to confirm the code selected with the tabular list. the guidelines and conventions. 83 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 265) 42
How do I code for whiplash? 847.0: Sprain of neck Using GEMs / code map (p. 122) 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) How do I code for whiplash? 847.0: 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. 43
How do I code for whiplash? 847.0: 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? 847.0: 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.xxA maps backward to 847.0 44
How do I code for DDD? Using GEMs / code map, we find: 722.4: degeneration of a cervical intervertebral disc M50.30 other cervical disc degeneration, unspecified cervical region Unspecified codes should be avoided, if possible How do I code for DDD? On our own, we find: 722.4: degeneration of a cervical intervertebral disc 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 45
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 91 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. 92 46
What does the documentation look like? 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 http://www.aapc.com/icd-10/icd-10-documentation-example.aspx 93 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: 847.0 Cervical sprain 339.21 Acute post-traumatic headache E813.0 Motor vehicle traffic accident involving collision with other vehicle; driver of motor vehicle other than motorcycle injured 94 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: 847.0 Cervical sprain 339.21 Acute post-traumatic headache E813.0 Motor vehicle traffic accident involving collision with other vehicle; driver of motor vehicle other than motorcycle injured 95 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: 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. 96 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: 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. 97 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: 847.0 Cervical sprain 339.21 Acute post-traumatic headache E813.0 Motor vehicle traffic accident involving collision with other vehicle; driver of motor vehicle other than motorcycle injured 98 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: 339.21 Acute post-traumatic headache GEMs suggest: G44.319 Acute post-traumatic headache, not intractable Note: In the index G44.319 is next to G44.311 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. 99 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: 847.0 Cervical sprain 339.21 Acute post-traumatic headache E813.0 Motor vehicle traffic accident involving collision with other vehicle; driver of motor vehicle other than motorcycle injured 100 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) 101 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 G44.311 Acute post-traumatic headache, intractable V49.40xA Driver injured in collision with unspecified motor vehicle, traffic accident, initial encounter Y92.411 Interstate as place of occurrence of the external cause 102 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 G44.311 Acute post-traumatic headache, intractable V49.40xA Driver injured in collision with unspecified motor vehicle, traffic accident, initial encounter Y92.411 Interstate as place of occurrence of the external cause 103 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 G44.311 Acute post-traumatic headache, intractable V49.40xA Driver injured in collision with unspecified motor vehicle, traffic accident, initial encounter Y92.411 Interstate as place of occurrence of the external cause 104 52
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 G44.311 Acute post-traumatic headache, intractable V49.40xA Driver injured in collision with unspecified motor vehicle, traffic accident, initial encounter Y92.411 Interstate as place of occurrence of the external cause 105 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 G44.311 Acute post-traumatic headache, intractable V49.40xA Driver injured in collision with unspecified motor vehicle, traffic accident, initial encounter Y92.411 Interstate as place of occurrence of the external cause 106 53
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 G44.311 Acute post-traumatic headache, intractable V49.40xA Driver injured in collision with unspecified motor vehicle, traffic accident, initial encounter Y92.411 Interstate as place of occurrence of the external cause 107 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 G44.311 Acute post-traumatic headache, intractable V49.40xA Driver injured in collision with unspecified motor vehicle, traffic accident, initial encounter Y92.411 Interstate as place of occurrence of the external cause 108 54
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 G44.311 Acute post-traumatic headache, intractable V49.40xA Driver injured in collision with unspecified motor vehicle, traffic accident, initial encounter Y92.411 Interstate as place of occurrence of the external cause 109 Example You diagnose a patient with the ICD-9 code 723.3 Cervicobrachial syndrome. o Cervicobrachial syndrome (diffuse) is a term used to indicate a collection of symptoms that arise due to the anterior (inside) neck muscles compressing the nerve root known as the brachial plexus, which controls movement of and sensation from the nerves of the shoulder and arm. This disorder presents with pain that radiates from the shoulder to the arm and/or the back of the neck, and may also present with muscle weakness in the arm. A code map using GEMs (pages 55-131) says that the ICD-10 code could be: M53.1 Cervicobrachial syndrome The alphabetic index (pages 441-457) 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 110 55
Example 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. 111 Quiz #10. Patient presents with pain, weakness, numbness, and tingling in both legs. The final diagnosis is bilateral sciatica. a) M54.41, M54.42 b) M54.31, M54.32 c) M54.5 d) M54.9 What method did you use to find the answer? 112 56
How do I implement ICD-10 in my practice? ICD-10 Myths October 1, 2014 will be the end of the world 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 will make ICD-10 impossible to use ICD-10 is already out of date ICD-10 will replace CPT http://www.cms.gov/medicare/coding/icd10/downloads/icd-10mythsandfacts.pdf How do I implement ICD-10 in my practice? 114 57
115 Which parts of a practice will be affected? Front Desk System updates, training Providers Management Documentation with more Vendor and payer contracts specificity Budgeting New code specific training Training plan Compliance plan, coding guidelines 58
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?) How do I implement ICD-10 in my practice? 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. 118 59
How do I implement ICD-10 in my practice? Readiness Survey: 1. What do you already know about ICD-10? 2. Why are we changing? 3. How much do you think ICD-10 will affect your clinic? 4. What specific questions would you like answered on ICD-10? 5. Where do you plan to go for more information? How do I implement ICD-10 in my practice? Questions for your software vendors: What implementation plans do you have in place? What software changes will be needed (if any)? What products and services will be available? When will you be ready to test your program? What guidance and assistance will you provide during the rollout? Is your clearinghouse ready? http://www.cms.gov/medicare/coding/icd10/downloads /ICD10TalkingtoVendorforMedicalPractices.pdf 60
How do I implement ICD-10 in my practice? Budgeting for ICD-10 falls into four categories: 1. Information systems upgrades 2. Auditing and monitoring documentation for ICD-10 3. Education and training 4. Staffing and overtime costs 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. How do I implement ICD-10 in my practice? 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 61
How do I implement ICD-10 in my practice? 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. How do I implement ICD-10 in my practice? Medicare: free training ChiroCode.com: free email 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 62
How do I implement ICD-10 in my practice? How do I implement ICD-10 in my practice? 1. Learn the basics-review these notes again with your whole office 2. Buy ChiroCode Complete and Easy ICD-10 Coding for Chiropractic or some other comprehensive resource 3. Dedicate a few minutes of each office meeting to ICD-10 1. Assign someone to read ten pages from the book, then report on what they learned (only 45 intro pages). 2. Find articles in Chiropractic trade journals and share them at each meeting. 3. Run a report with the list of most common ICD-9 codes, then create your own crosswalk 4. Take a real patient file and crosswalk it to ICD-10, then rework the documentation. 63
How do I implement ICD-10 in my practice? 5. Use the project management steps in the book (page 36) to keep on track. You will: 1. Plan a budget for implementation expenses 2. Create an internal crosswalk 3. Update all your forms 4. Contact all your vendors 5. Conduct internal testing 6. Use ChiroCode Consulting services if you need help. 7. 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. 128 64
Is ICD-10 good. or bad? Recommendation: don t procrastinate. 129 Procrastination 130 65
Education Dr. Evan Gwilliam Bachelor s of Science, Accounting - Brigham Young University Master s of Business Administration - Broadview University Doctor of Chiropractic, Valedictorian - Palmer College of Chiropractic Certifications Certified Professional Coder (CPC) - AAPC Nationally Certified Insurance Coding Specialist (NCICS) - NCCT Certified Chiropractic Professional Coder (CCPC) - AAPC ChiroCode Certified Chiropractic Professional Coder (CCCPC) - ChiroCode Certified Professional Coder Instructor (CPC-I) - AAPC Medical Compliance Specialist Physician (MCS-P) - MCS Certified Professional Medical Auditor (CPMA) AAPC, NAMAS Certified ICD-10 Trainer - AAPC 131 Dr. Evan Gwilliam Affiliations / Experience Chiropractic Practice in Washington and Utah Executive Director of Education and Consulting ChiroCode Institute Editorial Board Member - ICD10Monitor.com Speaker/Instructor Cross Country Education, ChiroCode, Target Coding, AAPC, multiple state associations Contributor Chiropractic Economics, ACANews, AAPC Cutting Edge, The American Chiropractor Member National Alliance of Medical Auditing Specialists 132 66