December 14, 2015

Diagnosing Chiropractic “Subluxation” in ICD-10-CM

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Chiropractors use many of the same diagnosis codes as other providers that treat conditions of the nervous system, skeletal system, and muscular system. However, there is one diagnosis that’s unique to chiropractic doctors. It is the so-called vertebral “subluxation.” It is the diagnosis that justifies the performance of a chiropractic manipulative treatment, or an adjustment, which is by far the most commonly performed procedure in a chiropractic setting. 

 

Unfortunately, subluxation is defined differently by different groups. In a typical medical dictionary it is simply a “partial dislocation,” which implies some sort of torn ligaments and/or trauma. However, a different definition, such as the following from Medicare, should be considered for the chiropractic provider:

“A motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact. For the purposes of Medicare, subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebra anatomically." 

A recent U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) report about chiropractors says:

"Medicare requires that chiropractic claims have a primary diagnosis of ‘subluxation’ for payment, but there is no diagnosis code that contains the word ‘subluxation.’ CMS has instructed chiropractors to use the diagnosis codes that indicate non-allopathic lesions of the spine."

This was the 739 category in ICD-9-CM. The inclusion terms for the 739 category include “segmental and somatic dysfunction” but make no mention of the word “subluxation.” Nonetheless, most private payers followed Medicare’s lead and accepted the 739 category as a justification to provide chiropractic manipulative treatment (the 9894X codes from CPT). 

The spinal codes that actually contained the word “subluxation” in ICD-9 (839 category) were consistent with the “partial dislocation” viewpoint. Dislocations are often treated with immobilization and/or medication by medical professionals. In fact, it may be contraindicated to manipulate or adjust a dislocated segment. Some payers did accept the 839 codes, but, using the medical definition, a coder might argue that it does not justify chiropractic treatment. Chiropractors have been compelled to try to fit a square peg into a round hole for many years.  

Along came ICD-10-CM, and it brought a few new considerations, but not necessarily a solution. The clear replacement for 739 codes are the M99.0 codes, which are “segmental and somatic dysfunction.” The word “subluxation” is still missing. However, these are the codes that most Medicare contractors have instructed chiropractors to use, and private payers appear to have followed suit. 

The next group of codes in the tabular List are in the M99.1 subcategory, which is defined as “subluxation complex (vertebral).” These codes appear to use the verbiage many chiropractors are looking for, but unfortunately, they are not listed on any Medicare-approved lists. This may be because the word “subluxation” in these codes still means “partial dislocation” to coders and payers. Since Medicare has not listed these codes as acceptable, it appears that they may not be payable (as justification for manipulation), despite the fact that they are valid. 

The injury section of Chapter 19 of ICD-10-CM offers codes that also appear to use the proper term as described by doctors of chiropractic: S13.1 for cervical subluxations, S23.1 for thoracic subluxations, and S33.1 for lumbar subluxations (with the sixth character “0”). However, there are several reasons why these may not be the best option:

  • They are the matches for the old 839 category, which was not payable by Medicare.
  • This entire chapter is for acute injuries, and the “includes” list for each of these categories include sprains and other serious traumatic issues. Many chiropractic patients have a chiropractic “subluxation” without trauma.
  • To use these codes, the provider also must document a specific interspace to explain which bone is dislocated. However, the chiropractic subluxation usually describes a segment (not the space between two segments) that is misaligned or fixated.
  • There are no subluxation codes offered in these ranges for L5/S1 or the sacroiliac joints. But these are joints that are typically treated by chiropractors.
  • These codes also require a seventh character to designate the episode of care, which is a bit confusing if you try to force it into the chiropractic model.

It appears that these codes are not really ideal for the chiropractically defined subluxation, but work just fine if you are trying to describe a dislocation. And dislocations typically need to be immobilized rather than manipulated. It may be wise to check with specific payers before using these codes to justify manipulation. 

This brings us back to M99.0 codes, which Medicare has recommended. However, the documentation should match the diagnosis code selected for a claim. If the documentation says “subluxation,” the most correct code would be from Chapter 19’s “S” injury codes. If it says “subluxation complex,” then the M99.1 codes are the best match. But since both of those are potentially problematic, it may be best to document something like “segmental dysfunction (subluxation)” so that the M99.0 codes are the clear choice.

Throwing the word “subluxation” in there in parentheses lets the payers know that you are using the code they prefer, while still documenting what the patient really has. 

 

Evan M. Gwilliam, DC, MBA, BS, CPC, CCPC, CCCPC, NCICS, CPC-I MCS-P, CPMA

Evan M. Gwilliam, DC, MBA, BS, CPC, CCPC, CCCPC, NCICS, CPC-I MCS-P, CPMA, executive vice president of ChiroCode and Find-A-Code LLC, graduated from Palmer College of Chiropractic as valedictorian and is a certified professional coding instructor, medical compliance specialist, and professional medical auditor, among other things. He provides expert witness reports, medical record audits, consulting, and online courses for healthcare providers. He also writes books and articles for trade journals and is a sought-after seminar speaker. He has a bachelor’s degree in accounting and a master’s of business administration, and he is one of the few clinicians who is a certified ICD-10 Instructor and certified MACRA/MIPS healthcare professional. 

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