ICD-10 Guidelines for DCs
SOURCE: ACA News ~ April 2014
By Evan M. Gwilliam, DC
The ICD-10 codes that will soon be used on CMS-1500 claim forms have many pages of guidelines that explain the rules and conventions necessary to apply them correctly. Depending on the publisher, they take up about 30 pages in the ICD-10-CM code set. Some explain items like the definition of “Excludes2” and the meaning of the semicolon or slanted brackets (see Sections 1.A and 1.B). The bulk of these guidelines, around 20 pages, are found in Section 1.C and are chapter specific. The ICD-10-CM code set is divided into 21 chapters, each one for a distinct body system or condition.
Chiropractic physicians typically use codes from just four or five of the 21 chapters available in ICD-10-CM. These include, but are not necessarily limited to, the codes from Chapter 6, diseases of the nervous system; Chapter 13, diseases of the musculoskeletal system and connective tissue; Chapter 18, symptoms, signs and abnormal clinical findings, not elsewhere classified; Chapter 19, injury, poisoning and certain other consequences of external causes. Most doctors of chiropractic (DCs) do not employ certified coders to research all of the coding changes that are specific to their specialty. They are compelled to learn coding while running a small business and continuing to focus on the clinical needs of their patients. A thorough understanding of all the guidelines in ICD-10-CM is wise, but listed below are a handful of guidelines that should be the focus.
Chapter 6 Guidelines
Chapter 6 (diseases of the nervous system) includes codes from G00 to G99, covering the nervous system. DCs frequently treat many conditions of the nervous system, but only a few guidelines are important in the typical chiropractic setting. Some chiropractic patients may suffer from hemiplegia (G81) or monoplegia (G83). The guidelines tell us that the dominant or nondominant side can be affected and should be identified. However, if dominance is not specified, code selection follows these rules:
- For ambidextrous patients, the default should be dominant;
- If the left side is affected, the default is non-dominant; and
- If the right side is affected, the default is dominant.
The general code set guidelines tell us to report only codes for conditions that are being treated or that directly affect the treatment. If a patient presents with hemiplegia (G81) that does not affect the treatment in any way, it will not be reported.
Chapter 6 also contains codes in the G89 category for pain associated with surgery, neoplasms or other chronic pain. The guidelines explain that these codes should not be used if the underlying diagnosis is known unless the reason for the encounter is pain management. Pain management may not be a primary diagnosis most payers would recognize when billed by a DC, but it can still be used if the criteria are met. Conditions such as spine or joint pain can be coded from Chapter 18, but G89 can be used as a secondary code if it provides additional information. For DCs, the site-specific code (such as cervicalgia, M54.2) would generally be listed first. Note also that the time frame to designate pain as “chronic” for code G89.2 is not defined.
Chapter 13 Guidelines
Chapter 13 (diseases of the musculoskeletal system and connective tissue) may be the most used section of all of ICD-10 for doctors of chiropractic. Fortunately, the guidelines for this chapter are fairly straightforward. “Site” is defined as the bone, joint or muscle involved. Some conditions have a code for multiple sites, and we are told to use this code instead of listing all the individual sites when it is available. If there is no multiple-site code, then it is acceptable to code every site separately.
Some conditions affect the end of a bone, which should not be confused with the joint itself. For example, a condition of the proximal ulna would be classified to the ulna, not the elbow joint. In addition, chronic or recurrent conditions are usually coded from Chapter 13, but current, acute injuries would be more appropriately coded from Chapter 19, the injury chapter.
Chapter 18 Guidelines
Although there are not many codes to choose from for the chiropractic physician in Chapter 18 (i.e., symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified), they may be used when a more definitive diagnosis has not been established by the provider. The doctor may be waiting for results from an MRI or other imaging before he or she chooses a more definitive code from Chapter 13 (musculoskeletal) or 19 (injuries). Signs and symptoms may be coded along with the definitive diagnosis when they are not routinely associated with it, but the definitive diagnosis code should always be listed first. If the symptom is typically associated with the more definitive diagnosis, then it should not be used. For example, R11.10, vomiting, would not be coded along with G43. A, cyclical vomiting associated with migraine. Combination codes that include the symptom do not need a code from Chapter 18 either.
Chapter 19 Guidelines
Chapter 19 (Injury, poisoning and certain other consequences of external causes) codes will be used by providers involved in physical medicine. Many of these codes include the seventh-character extension that describes the encounter. The guidelines tell us that the seventh character “A” is for active treatment, such as surgical treatment, ER encounters and evaluation and treatment by a new physician. The seventh character “D” is for subsequent encounters, which may include routine care during the healing or recovery phase, such as aftercare and follow-up visits. The “S” is for sequela, which is for complications that arise as a direct result of a condition.
When coding injuries, it is important to list the most serious one first. This would be the code that represents the primary focus of the treatment. Superficial injuries, such as bruises sustained in a fall or an auto-related injury do not need to be coded if a code for a more serious injury in the same site is already being used.
The official guidelines in ICD-10 go on for pages and pages, but this quick synopsis summarizes those that most DCs should be aware of. However, all doctors need to review the complete guidelines to ensure that they apply the codes correctly to each patient encounter. We hope that this saves the busy solo doctor from wading through the fine print in the guidelines so that he or she can get back to doing what the DC does best – taking care of patients.
Complete and Easy ICD-10 Coding for Chiropractic, second edition. The ChiroCode Institute, 2013
Dr. Gwilliam has an MBA and multiple certifications in coding, compliance and auditing. He is the director of education and consulting for ACA’s corporate partner, ChiroCode Institute, and is the only chiropractor who is also an AAPC Certified ICD-10 Trainer. He spends most of his time teaching chiropractic physicians and other health professionals how to get ready for ICD-10. He can be reached at DrG@ChiroCode.com.