January 27, 2014

ICD-10 Guidelines that Chiropractic Physicians Should Remember

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Depending on the publisher, there are about 30 pages of guidelines in the ICD-10-CM code set. The bulk of these guidelines, from section 1.C, are chapter-specific.

 

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), and Chapter 19 (Injury, Poisoning and Certain Other Consequences of External Causes). Unlike many other healthcare professionals in larger clinic systems, chiropractic doctors rarely have certified coders or staff with any specialized coding training. They are compelled to learn coding and keep up with changes while still running their business and keeping their clinical skills sharp. Reflecting an effort to make it easier for these small clinics, here are some relevant points from the chapter-specific guidelines that are likely to matter to chiropractors. 

Chapter 6 includes codes from G00 to G99, covering the nervous system. Chiropractors frequently treat many conditions of the nervous system, but only a few guidelines are important in the typical chiropractic setting. Some patients may suffer from hemiplegia (G81) or monoplegia (G83). The guidelines tell us that the dominant or non-dominant 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.
  • If the right side is affected, the default is dominant.

Chapter 6 (Diseases of the Nervous System) also contains codes in the G89 category for pain associated with surgery, neoplasms, or some other chronic source. The guidelines indicate 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 payors would recognize when billed by a chiropractor, but it can still be used if the criteria is met. Conditions such as spine or joint pain can be coded from Chapter 18, but G89 still can be used as a secondary code if it provides additional information. For chiropractors, the site-specific code generally would be listed first. Note also that the time frame to designate pain as “chronic” for code G89.2 is not defined.

Chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue) may be the most-used section of all of ICD-10 for chiropractic physicians. “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 of 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 a 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 usually are coded from Chapter 13, but current, acute injuries would be more appropriately coded from Chapter 19, the injury chapter. 

Though there are not many codes to choose from for the chiropractic physician in Chapter 18 (Symptoms, Signs, and Abnormal Clinical and Laboratory Findings not Elsewhere Classified), they may be used quite often 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 code from Chapter 13 or 19. 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, cyclical vomiting associated with migraine. Combination codes that include the symptom do not need a code from Chapter 18 either. 

Chapter 19 (Injury, Poisoning, and Certain Other Consequences of External Causes) includes codes that will be used by many providers involved in physical medicine. Many of these codes include the seventh-character extension, which 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, or complications that arise as a direct result of a condition. 

These seventh characters can be interpreted a number of ways with regard to the way that chiropractic care is typically delivered. Medicare will only reimburse chiropractors for procedures delivered as “active care,” which is the same phrase used with the “A” character. It may be the case that chiropractic care will only be reimbursable for applicable codes with this character. However, chiropractic doctors often perform assessment visits before and after several weeks of treatment visits, when the therapy is delivered. These treatment visits sound like a good fit for routine care rendered during healing, or aftercare, indicated by the “D” character. The “S” for sequela might be used by chiropractors when a patient suffered an injury that leads to degenerative joint disease a year later, but it also could be interpreted to be synonymous with maintenance care, which is not typically considered medically necessary. (When I teach my training seminars, I advise doctors that we just need to wait to see how the payors decide to interpret these guidelines.)

When coding injuries, it is important to list the most serious one first. This would be whichever one is the primary focus of the treatment. Superficial injuries, such as bruises sustained in a fall or auto-related injury, would not need to be coded if a code for a more serious injury in the same site is already being used. 

The official ICD-10 guidelines go on for pages and pages, but this quick synopsis summarizes those chapters and codes of which most doctors of chiropractic should be aware. Hopefully, this saves the busy solo doctor from wading through all of the fine print in the guidelines so he or she can get back to doing what he or she does best – take care of patients. 

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.