With massive expansion in the number of medical codes, ICD-10 provides chiropractors with more specific codes to report diagnosis more clearly and thereby reduce claim denials. It is estimated that ICD-10 transition affected 200 codes commonly used by chiropractors. Now, chiropractic medical coding requires a diagnosis hierarchy – first neurological, then structural, functional and finally soft tissue. The specificity of laterality is also required, wherever applicable. Let’s take a detailed look at ICD-10 structure, characteristics and effective coding practices.
ICD-10 Structure
Unlike ICD-9, ICD-10 codes have seven characters which denote the following:
- The first three characters denote the category. All codes under the same category are a related condition. For example, M86 is the category for Osteomyelitis.
- The next three characters specify the details regarding anatomical site and severity. The sixth character often denotes laterality (1=right; 2=left). For example, in case of M86.011 Acute hematogenous osteomyelitis, right shoulder, 011 denotes it is acute hematogenous osteomyelitis on the right shoulder.
- The seventh character is for certain injury codes to denote encounter or episode of care. This is particularly important when using sprain and strain codes. There are three options such as:
- Initial Encounter – This indicates the patient is receiving active treatment (For example, S93.01XA: Subluxation of right ankle joint, initial encounter). Payers may consider this as a phase of care rather than a single visit. But, it may be required to specify this episode of care while establishing medical necessity for chiropractic care.
- Subsequent Encounter – This indicates routine care during the healing or recovery phase/support care (For example, S93.01XD: Subluxation of right ankle joint, subsequent encounter). Specifying this episode of care may be considered for every visit after the initial visit, or it may be viewed as maintenance care.
- Sequela – This indicates complications or conditions that arise as a direct result of a condition, which is no longer present, but led to another problem that is the primary reason for the encounter (For example, S93.01XS: Subluxation of right ankle joint, initial encounter)
Important Characteristics
- Acute and Chronic Conditions – ICD-10 codes specify both acute and chronic conditions. Acute conditions are characterized by sudden onset, severe change and/or short duration while chronic conditions are characterized by long duration, frequent recurrence over a long period of time, and/or slow progression over time. Examples are M86.0: Acute hematogenous osteomyelitis and M86.3: Chronic multifocal osteomyelitis.
- Additional Diagnosis – The secondary diagnosis used, if it is available in order to give a more complete picture of the primary diagnosis.
- Bilateral – The final characters of the ICD-10 codes specify laterality for the bilateral sites. The ICD-10 medical coding system also provides an unspecified code for the sites that are not identified in the medical record. If the condition is bilateral and no bilateral code is provided, you should assign separate codes for both the left and right side.
- Code Also – It is possible to assign more than one code if it does not imply any sequencing guidance. Typically, the most serious condition needs to be listed first.
- Combination Codes – This refers to using a single code to specify two diagnoses, a diagnosis with an associated secondary process (manifestation) or a diagnosis with an associated complication. For example, there are codes for right and left sciatica with lumbago (M54.41 and M54.42 respectively).
- Excludes 1 and 2 – Unlike ICD-9, there are two types of excludes in the ICD-10 system. You should use the codes/conditions listed in the “Excludes1” notes as the two conditions do not occur together. It may be useful to consider the “Excludes1” list to be codes that might be suggested instead. The codes/conditions listed in the “Excludes2” notes indicate that the condition being excluded is not considered part of the subject condition and it is required to assign another code. It may be useful to consider “Excludes2” codes that might need to be added to give complete details. The ICD-10 codes may have both, either or neither Excludes1 and Excludes2 note.
- NEC –This is used when the information in the medical record specifies detail for which specific codes are not available. For example, M53.3 Sacrococcygeal disorders, not elsewhere classified.
- Non Essential Modifiers – These are the terms that may coexist with the main term, but they won’t change the code assignment for that particular condition. Non essential modifiers are generally contained within parentheses. An example is S10.82: Blister (non-thermal) of other specified part of neck.
- NOS – This refers to ‘Not otherwise specified’ or ‘unspecified. This is used when the information in the medical record is not sufficient to assign a more specific code. Both the code and documentation are vague. An example is M51.9: Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder.
- Medical Necessity – The services or supplies are typically considered to be medically necessary if they are proper and required for the diagnosis or treatment of a medical condition, provided for the diagnosis, direct care and treatment of a medical condition and meet the standards of good medical practice in the local area and not mainly the convenience of the patient or doctor. You should not only ensure that your documentation is proper and also use diagnosis codes to convey this information.
General Tips for Effective Coding
- Do not code diagnoses that are documented as “probable”, “suspected”, “questionable”, “rule out” or “working diagnosis” or other terms indicating uncertainty.
- Code signs and symptoms only if a more definitive diagnosis has not been identified or if they are not routinely associated with other codes that are assigned to the encounter.
- External cause codes (Chapter 20, V, W, X, and Y) should be used if the documentation provides data about the location activity or circumstances of an injury or poisoning, and does not provide a diagnosis. Though they are not mandatory, voluntary reporting should be encouraged. These codes can be used for acute injuries such as accidents on workers’ compensation claims.
With unique characteristics, ICD-10 coding can be complex and challenging to chiropractors. It is advisable to obtain reliable support from a professional medical billing and coding company that provides the service of AAPC-certified coders well-trained in ICD-10 medical coding.
Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.