Updated on: March 14, 2016

The ICD-10 Documentation Challenge for Chiropractic Physicians

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Original story posted on: September 16, 2013

According to the Office of the Inspector General (OIG), which is like the police force for government programs, doctors of chiropractic (DCs) have a less-than-stellar track record when it comes to documentation. The OIG issued a report in 2005 regarding Medicare’s payment for chiropractic services. Based on data from 2001, the OIG concluded that 67 percent of chiropractic claims were paid in error or fraudulent.

 

This was due in part to insufficient documentation. As a result, the recommendation was made to the Centers for Medicare & Medicaid Services (CMS) to cap the number of chiropractic treatments available for reimbursement.

Later it was uncovered that in 2006, Medicare inappropriately paid $178 million (out of $466 million) for chiropractic claims for services that medical reviewers determined to be maintenance therapy ($157 million), undocumented ($46 million), or miscoded ($11 million). These claims represented 47 percent of all allowed chiropractic claims that met the study criteria at the time.

If you were to travel through time to Oct. 1, 2014, you might see some chiropractic physicians scrambling to keep up with the increased demands of proper documentation associated with ICD-10. However, according to a recent release from the Medicare Learning Network (MLN), most documentation required for ICD-10 is already being created. For example, a doctor may specify that sciatica is presenting on the right, but ICD-9 codes don’t differentiate laterality. This information will be critical, however, in the selection of the proper ICD-10 codes. The MLN document also reminds providers that coding should be based on the documentation, not a corresponding crosswalk from ICD-9. Documentation supporting more specific codes will provide higher quality data, which can in turn help researchers to understand outcomes and efficacy of care better. This is one of the main purposes of ICD-10: to provide data that can be used to control costs while simultaneously improving quality.

ICD-9 may have lulled some providers into a false sense of security. Less detailed documentation may be sufficient for some ICD-9 codes. Here is a sample of some differences between documentation requirements for some common ICD-9 codes for DCs versus ICD-10 codes for DCs. Let’s say that the doctor simply noted the following:

“Exam findings are consistent with cervical sprain/strain and acute cephalgia due to motor vehicle accident.”

 

In ICD-9, the applicable codes might be:

847.0 Cervical sprain

339.21 Acute post-traumatic headache

E813.0 Motor vehicle traffic accident involving collision with other vehicle; driver of motor vehicle other than motorcycle injured

General equivalence mappings (GEMs) suggest the following ICD-10 codes:

S13.4XXA Sprain of ligaments of the cervical spine, initial encounter

or

S13.8XXA Sprain of other parts of the neck, initial encounter

and

G44.319 Acute post-traumatic headache, not intractable

and

No suggestions for the E-code.

In order to select the proper sprain code, more detail is needed. In order to select the proper headache code, the provider must document whether or not it is intractable (which means “hard to deal with or control”). GEMs do not provide the option G44.311, which is intractable, but an astute coder would know to look through the code set and compare the choices to the documentation before selecting the right code. More detail about the accident is also necessary to record the circumstances and location of the accident.


Therefore, the current documentation is insufficient, and GEMs do not provide enough guidance to code this scenario. In order to select the proper ICD-10 codes, the note must read something like this:

“Exam findings are consistent with sprain of the ligaments of the cervical spine and acute traumatic headache that does not respond to over-the-counter medications. Patient was the driver of a vehicle that collided with another motor vehicle on the interstate. He was not treated at the scene.”

The proper ICD-10 codes in this case are:

S13.4XXA Sprain of ligaments of the cervical spine, initial encounter

G44.311 Acute post-traumatic headache, intractable

V49.40XA Driver injured in collision with unspecified motor vehicle, traffic accident, initial encounter

Y92.411 Interstate as place of occurrence of the external cause

In ICD-10, again, more information must be documented before the proper codes can be selected. The factors that must be documented are not excessive, however. In fact, doctors probably should be recording this information already. However, having knowledge of the codes they likely will use and the factors they describe will assist providers as they work to make sure that codes and documentation are in agreement. E-codes, or external cause codes, are not commonly used now. Requirements vary by payor. CMS has assured us that we won’t be required to use ICD-10 E-codes (the V and Y codes from this example), but we are encouraged to do so. It will assist in data collection for a number of purposes, one of which might be public health and safety initiatives.

Will documentation be a challenge for some providers? Certainly, yes. However, providers can prepare by taking their own completed claims and going through the same exercise demonstrated here. If they tackle two or three of these each month leading up to the Oct. 1, 2014 implementation date, the documentation requirements should be familiar and the transition should be smooth.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
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.