March 26, 2013

Which ICD-10-CM Codes Will Chiropractic Physicians Use to Bill Third Parties?

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In my previous article I went into detail about which ICD-10 codes most likely could replace some common ICD-9 cervical diagnoses currently used by chiropractic physicians. This is the last article in a series investigating those possibilities. Here, the focus will shift to another area commonly treated by chiropractors: the lumbar spine.

 

The ICD-9 codes selected as a starting point are taken from the Medicare Local Coverage Determination (LCD) for Arizona, whose Medicare Administrative Contractor (MAC) is Noridian. Though the General Equivalence Mappings (GEMs) written by the National Center for Health Statistics (NCHS) are only approximations, they will be used as a starting point for crosswalking from ICD-9 to ICD-10. This approach also may be useful for those attempting to create their own internal crosswalks for their clinics as they begin to prepare for ICD-10 implementation in October 2014.

Since Medicare sets the tone for other payers, we can hope that my predictions will apply to private payers as well. Based on the information available to providers at this time, I think these are fairly reasonable guesses, too.

The Medicare LCD for chiropractic practice places diagnosis codes into three categories, with progressively longer treatment times. I have chosen one code from each category to focus on here. They are 724.2 lumbago, 724.4 thoracic or lumbosacral neuritis or radiculitis, unspecified; and 724.3 sciatica.

724.2 lumbago is a Category I code on the LCD; that is, Medicare recognizes it as only requiring a short term of treatment. This code is very general and does not provide much information about the cause of the back pain. The ICD-9 description includes the words “low back pain, low back syndrome, and lumbalgia” as well. It only should be used when a more descriptive code from 720-724 is not available. GEMs take us to M54.5 low back pain, loin pain, and lumbago NOS. This definition is slightly different from that of the old code, but an interesting fact is that this code has an “Excludes 1” note. Excludes 1 is a new convention in ICD-10. It means that the excluded codes should never be coded at the same time as the code above the note. These include S39.012 low back strain, M51.2- lumbago due to intervertebral disc displacement, and M54.4- lumbago with sciatica. It is important to note that these conditions are more serious and usually warrant more intense care than mere low back pain. In the past physicians may have been content to use 724.2, but greater detail is necessary to code using ICD-10. In this case, that greater detail can mean more income earned by documenting the need for a longer duration of care.

724.4 thoracic or lumbosacral neuritis or radiculitis unspecified is a Category II code on the Medicare LCD. This means that Medicare recognizes that it may reflect a moderate term of treatment. In ICD-9, the definition also includes “radicular syndrome of the lower limbs.” In these two conditions, the patient suffers from severe pain, burning, or tingling sensations in one or both legs, and it worsens with movement. The cause of neuritis is unknown, but it is thought to be connected to an autoimmune disorder. Radiculitis, which is more commonly associated with chiropractic care, results from swelling due to trauma to the nerves.

The mapping of this code to ICD-10 offers a good example of why the ICD-10 code set is so much larger than ICD-9: we go from one code to four. GEMs take us to M54.14, M54.15, M54.16, and M54.17. These four codes reflect “radiculopathy,” followed by the specific region of the lower spine. Coders must know their spinal anatomy well in order to select the correct code. The category M54.1 also lists four Excludes 1 codes. They are primarily combination codes, which include radiculopathy in their definitions along with a more descriptive cause such as spondylosis. The ICD-10 Medicare LCD likely will list all four codes from the GEMs as well as most of these Excludes 1 codes in place of this single ICD-9 code.

724.3 sciatica, neuralgia or neuritis of the sciatic nerve, is a code used to describe a condition treated quite frequently in the average chiropractic office. It falls into Medicare’s Category III, reflecting a possible requirement of long-term treatment. The other codes in this category represent severe neurological and structural diagnoses. Sciatica is characterized by sharp shooting pain or numbness and muscle weakness from the lower back down the rear of one leg. It is usually the result of pressure on a nerve from a herniated disc. In ICD-9, this code excludes more specific lesions of the sciatic nerve from 355.0, which are frequently traumatic. The 355 code is not a diagnosis covered by Medicare for chiropractic physicians.

The GEMs crosswalk here leads to M54.30 sciatica, unspecified side. The word “unspecified” is a red flag because it likely will be excluded from the list of codes that Medicare recognizes as representing medically necessary reasons for chiropractic treatment. Fortunately, the writers of ICD-10 were well aware that ICD-9 lacked codes that differentiated laterality. Hence, physicians now must specify right- or left-sided sciatica with M54.31 and M54.32. In fact, just little farther down the page in ICD-10, there are codes for right and left sciatica with lumbago (M54.41 and M54.42). This is a nice example of a combination code that was not available at all in ICD-9. All of these codes probably will be added to the Medicare LCD.

This concludes the three-article series about possible ICD-10 codes for chiropractors. In each example I hope you learned a little more about why ICD-10 was created and how it will be different for coders who work in a chiropractic physician’s office. Once Medicare and other payors finally release the codes they will approve for claim submission, these articles will have to be rewritten. For now, you have my best guesses.

References:

Noridian, Medicare LCD for Arizona, L24288, Chiropractic

www.FindACode.com

Chirocode Complete & Easy ICD-10 Coding For Chiropractic, First Edition, 2011

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.