By Alan Lyons, D.C.
The importance of proper coding of a diagnosis
cannot be overstressed. Accuracy is essential to reimbursement
for services rendered and to protection from both malpractice and
In the past several years, I have personally
collected dozens of diagnosis code lists -- from doctors,
software manufacturers, practice management/advisory groups and
billing seminars. Not one of these lists was written with the
exceptions/exclusions and specific requirements necessary to
proper coding. Without knowing the exceptions and exclusions
pertaining to a particular code it is almost certain that an
incorrect code will be used on a large percentage of patients.
Let's look at some examples:
353.0 brachial plexus compression
353.2 cervical root lesions
723.2 cervicocranial syndrome
723.3 cervicobrachial syndrome
723.8 cervical syndrome
724.02 lumbar spinal stenosis
724.5 backache (pain) syndrome
All of these codes are commonly used in many
chiropractic offices. However, all of these codes, as well as
many others, are specifically excluded in any condition,
which is in any way disc related, or involves spondylosis
(osteoarthritis). These 8 codes do not support chiropractic
manipulation because they do not describe a misalignment. It
is easy to understand how a chiropractor, without this knowledge
of exceptions, may erroneously code an incorrect diagnosis.
Repeatedly making incorrect diagnoses can lead
to problems with your State Board. Remember, the doctor has the
ultimate responsibility. Using a list full of mistakes and/or
omissions is no excuse. An incorrect diagnosis, followed by
repeated treatments, may also lead to indefensible malpractice
With the Americans With Disabilities Act more
disabled persons are filing A.D.A. claims. The Ninth Circuit
Court of Appeals has affirmed that a disabled person can be
stopped from pursuing an A.D.A. claim because of the way an
ATTORNEY OR DOCTOR documents the disability (e.g. inappropriate
ICD-9 code), or because of the manner in which the person with
the disability or the Doctor testifies at deposition, or both,
as a matter of law. (Kennedy v. Applause, Inc.) In
short, when you assign an inappropriate code, you may be sued,
and forced to pay for that person's disability!
Many of the codes may be interpreted as
applying to more than one area, with a slightly different
description relating that code to that anatomical area -- such as
728.85, muscle spasm, thoracic myospasm, etc. In some cases there
exists a considerable discretion as to the description, in others
there is none. Only with a codebook can you be sure.
USING ICD-9-CM CODES
a. Codes in the range 001.0 through 999.9 are
for the classification of diseases and injuries. Codes that
describe symptoms are only acceptable if that is the highest
level of diagnostic certainty documented by the doctor.
A) Diagnosis Codes Must Support the Procedure
Each service/procedure billed for a
patient should be supported by a diagnosis that would
substantiate those particular services or procedures, as
necessary in the investigation or treatment of their condition,
based on currently accepted standards of practice by the
Some of the "basic" HCFA guidelines are
summarized below. The focus is on guidelines that would affect
1. Indicate on the claim form or itemized
statement the appropriate code(s) from the ICD-9-CM code range
001.0 through V82.9 to identify diagnoses, symptoms, conditions,
complaints or other reason(s) for the procedure, service or
b. The codes V01.0 through V82.9 are to deal
with visits for circumstances other than disease or
2. The primary diagnosis should be listed
first. Additional codes for any current coexisting conditions are
3. ICD-9-CM codes should be listed at their
highest level of specificity.
a. Use three digit codes only if there are no
four digit codes within the coding category.
b. Use four digit codes only if there is no
fifth digit subclassification for that category.
c. Use the fifth digit subclassification for
those categories where it exists.
A code with insufficient digits may cause a
claim to be returned.
4. Diagnoses documented as "probable",
"suspected", "questionable", or "rule out" should NEVER be
coded as if they were confirmed.
5. When patients receive ancillary diagnostic
services ONLY during an encounter, the appropriate "V
code" for the service should be listed first, and the diagnosis
or problem for which the services are being performed listed
second. For example, code V72.5, Radiological examination, not
elsewhere classified, describes the reason for the encounter and
should be listed first on the claim form or statement. If the
reason for the referral is known, a second ICD-9-CM code, which
describes the signs, or symptoms for which the examination was
ordered should be listed. Failure to list a second ICD-9-CM code
in addition to the V code may result in claim delays or
6. 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.
7. In the presence of the diagnosis that is
the definitive cause of the patient's condition you are
prohibited from coding lesser specific diagnoses. If the
diagnosis is sprain/strain you NEVER code any symptom,
syndrome, radiation or observed factor, such as antalgia. They
are automatically included. If you code both the definitive cause
and a sign and/or symptom the insurance computer will kick out
your billing for review, delaying payment.
8. Do not code two definitive causes for the
same condition, such as a cervical sprain/strain and a cervical
subluxation. They are redundant IF you code both definitive
causes the insurance computer will kick out your billing for
review, delaying payment.
B) Medicare Penalties For
The penalties for non-compliance differ
depending upon whether or not the health care professional has
agreed to accept assignment or not.
1. For health care professionals who accept
assignment on a Medicare claim and who fail to include ICD-9-CM
codes as required will have their claim(s) returned for proper
coding and may be subject to post-payment review by the Medicare
intermediary, as well as payment denials.
2. For health care professionals who do not
accept assignment, the penalties are more severe.
a. If the original claim form does not
include ICD-9-CM codes, as required, and the health care
professional refuses to provide the codes promptly on request to
the Medicare intermediary, the professional may be subject to a
civil monetary penalty in an amount not to exceed $2,000.00, per
b. If the health care professional
continuously fails to provide the ICD-9-CM codes as requested,
the professional may be barred from participation in the Medicare
program for a period not to exceed five years.
3. For Medicare the service must be manual
manipulation of the spine. This service is reported by the
procedure codes for chiropractic manipulation.
4. The primary diagnosis must be subluxation
of the spine, either so stated or identified by a term
descriptive of the subluxation. The following diagnoses are
acceptable because they would always involve a subluxation (at
least according to the reference text):
intervertebral disc disorders
curvatures of the spine 737.0-
nonallopathic lesions 739.1-
5. The level of subluxation must be
Down coding is the process of reducing a
code from one of a higher value to one of a lower value which
results in lower reimbursement.
With procedure coding, down coding claims is
easily resolved by providing a procedure description which
matches that of Current Procedural Terminology (CPT) exactly, or,
even better, by eliminating all procedure descriptions. For
A key point to remember is that if there are
any current coexisting conditions which may COMPLICATE THE
TREATMENT FOR THE PRIMARY CONDITION, it is very important to
include the ICD-9-CM codes for the coexisting conditions which
will help to justify the level of service provided.
When you use a screening code from the V-code
section you should also code signs or symptoms. The reason is
most health insurance carriers do not provide coverage for
routine screening procedures or preventive medicine.
Categories 800-959 include fractures,
dislocations, sprains and various other types of injuries.
Injuries are classified first according to the general type of
injury and within each type there is a further breakdown by
In cases of multiple injuries, the most
severe injury is the principal diagnosis. Use the appropriate
E-Code to identify the cause of the injury.
Manifestations are characteristic signs or
symptoms of an illness. Signs and symptoms that point rather
definitely to a given diagnosis are assigned to the appropriate
chapter of ICD-9-CM. However, Chapter 16, encompassing categories
780-799, includes ill-defined conditions and symptoms that may
suggest two or more diseases or, may point to two or more systems
of the body, and are used in cases lacking the necessary study to
make a final diagnosis.
1. Cases for which no more specific diagnosis
can be made even after all the facts bearing on the case have
been investigated, for example, code 784.0 Headache.
2. Signs or symptoms existing at the time of
the initial encounter that proved to be transient and whose cause
could not be determined, for example, code 780.2 Syncope and
3. Provisional diagnoses in a patient who
failed to return for further investigation or care, for example,
code 786.52 Painful Respiration.
Using "V" Codes
V-codes are used to identify encounters
with the health care setting for reason other than an illness or
injury, for example, immunization. V-codes are also used to
identify encounters of persons who are injured or ill and whose
injury or illness is influenced by some circumstance or problem
classified to the
V-codes fall into one of three
categories; Problems, Services or Factual.
1. Problem: V-codes identify a
circumstance or problem that could affect a patient's overall
health status but is not itself a current illness or injury.
Coding a drug allergy is an example.
2. Service: V-codes describe
circumstances other than an illness or injury, which prompt the
patient's visit. This type of visit often occurs when the patient
has a chronic disease but is not acutely ill. An example would be
a patient with a known disc herniation who has sought a
maintenance spinal manipulation.
3. Factual: V-codes are used to
describe certain facts that do not fall into the "problem" or
"service" categories. For example, coding the type of birth using
code V30.1 - Single Liveborn prior to admission to
807.00 Fracture of ribs, closed,
V-codes can be used as a solo code, a
principal code or as a secondary code. It is important to use
V-codes properly. If a complication is present, the complication
should be coded to categories 001-799 instead of to a V-code.
Using "E" Codes
E-codes permit the classification of
environmental events, circumstances and conditions as the cause
of injury, poisoning and other adverse side effects. The use of
E-codes together with the code identifying the injury or
condition provides additional information of particular concern
to industrial medicine, insurance carriers, national safety
programs and public health agencies.
The E-codes may be assigned with any of the
codes in the main classification 001-999 to identify the external
cause of an injury or condition. E-codes are NEVER used as
solo codes or as principal diagnostic codes.
E-codes are important for providing details of
an accident to an insurance company to enable them to issue
faster and more accurate reimbursement. Since most insurance
carriers wait to be sure they reimburse only for services covered
under their policy and not for services covered under Worker's
Compensation or Automobile/Homeowner's insurance. A clear
understanding of the circumstances will eliminate questions from
the insurance carrier which cause delays in reimbursements.
When using E-codes always list the E-codes as
secondary or supplemental to the code(s) describing the
Coding Example: Fractured ribs due to
fall from ladder at home.
E881.0 Fall from ladder
E849.0 Place of occurrence, home
Coding Late Effects
You use late effects coding when coding
diagnostic statements that identify a residual effect (condition
produced) after the acute phase of an illness or injury has
ended. The proper coding sequence is the code number identifying
the residual (the current condition) to be listed first with the
code number identifying the cause (original illness/injury no
longer present in its acute phase but which was the cause of the
long term residual condition listed second. An appropriate late
effects E Code should be used, where possible, for injuries.
Other late-effects codes may be found in the Miscellaneous
Be sure to distinguish between a late effect
and a historical statement in a diagnosis. Whenever the statement
uses the terms "effects of old...," "sequela of...," or
"residuals of...," then code as late effects. If the diagnosis is
expressed in terms as "history of...," these are coded to
personal history of the illness or injury and are coded to the
V-Codes (V-10 to V-19).
Acute and Chronic Coding
1. If there are separate sub-entries for
acute, subacute and chronic, then use both codes sequencing the
code for the acute condition first.
2. If there are no sub-entries to identify
acute, subacute or chronic, ignore these adjectives when
selecting the code for the particular condition.
3. If a certain condition is described as a
subacute condition and the index does not provide a subentry
designating subacute, then code the condition as if it were
In patient's with multiple separate
injuries, each separate injury must have a completely separate
diagnostic statement. Code the most serious injury first.
Many have expressed interest in the
changeover date from the ICD-9-CM codes to the ICD-10 codes. The
Health Care Financing Administration (HCFA) official position is
that they will not be mandated for Medicare claims until "at
least the year 2000." You should hope they are never used, they
NOS Not Otherwise Specified. Equivalent
to Unspecified. This abbreviation refers to a lack of sufficient
detail in the statement of diagnosis to be able to assign it to a
more specific subdivision within the classification.
NEC Not Elsewhere Classified. Used
with ill-defined terms to alert the coder that a specific form of
the condition is classified differently. The category number for
the term including the NEC is to be used only when the coder
lacks the information necessary to code the term to a more
NOS and NEC codes are vague and non-specific
and should not be used to support manipulation, which does
require specific knowledge of the exact spinal level. Example:
segmental or somatic dysfunction.
Each office should have a copy of the current
year's ICD-9-CM, and a copy of the CPT code books. These may be
ordered by calling 1-800-MED-SHOP. Ask for ICD-9-CM Hospital
Edition, Volumes 1,2 & 3 (1 book), Color Coded and thumb
indexed and the current year's CPT code book, Professional
Edition. Another excellent book to have is the "Reimbursement
Manual For The Medical Office: A Comprehensive Guide To Coding,
Billing & Fee Management", Third Edition. I recommend the
yearly purchase of the ICD & CPT books.
Since we chiropractors manipulate the
articulations of the body the only diagnoses that would support
our manipulation would have to be descriptive of a misalignment.
Remember, the DIAGNOSIS MUST SUPPORT THE PROCEDURE. OA & DDD
complicate a patient's condition but it is the misalignment
(subluxation) that we manipulate. Stick to using diagnosis codes
you can defend.
Note For California Chiropractors: The
Industrial Medical Council has officially defined subluxation and
sprain/strain to be acute conditions. Then they defined acute as
being within the first thirty days from the date of injury. Get
in the habit of going from acute diagnoses to chronic diagnoses
before the thirtieth day after the date of injury or you may end
up losing a lot of money when the comp carriers finally realize
it. You cannot go back and change your past records.(e.g.,
your billing or diagnosis codes)
A chiropractor should NEVER EVER assign a
diagnosis code that describes a sign or symptom. ALWAYS end the
diagnostic coding statement with an E code, sometimes two E
Bonus Note! Do not assign a new
patient code unless the patient meets the following definition.
NEW PATIENT: A patient who has not been seen by a doctor of
the same type in that clinic within the last three
years. If the patient was seen in that clinic within the last
three years s/he is a continuing patient (99211-99215).
I worked with the California Attorney
General's office at the request of the SBCE. The Attorney
General, and several District Attorneys, are now prosecuting for
incorrect use of the Evaluation & Management codes. The
MOST IMPORTANT criteria to consider when selecting a code
are the CHIEF COMPLAINT. It is NOT the time spent.
In order to use higher than a level 1 code the complicating
factors that put the patient at increased risk of increased
morbidity or mortality must be described and