February 19, 2013

Which ICD-10-CM Codes Will Chiropractic Physicians Use to Bill Third Parties? - Part 2


In my previous article I went into detail about which ICD-10-CM codes would be most likely to replace the 739 primary diagnosis (Chiropractic subluxation) in ICD-9-CM. Using a Medicare local coverage determination (LCD) and the General Equivalence Mappings (GEMs) as a starting point, in this article I will attempt to predict which ICD-10-CM codes will be approved for the secondary cervical diagnoses Medicare uses now. (By the way, I just use the free FindACode app on my iPad to look these up, and you can too.)


My next article will touch on some common lumbar diagnoses. Since Medicare sets the tone for other payers, we then can hope that my predictions will apply to private payers as well. I realize that I make a lot of assumptions here, but this is the most logical approach I can devise with the information available at this time.

Fortunately, there are only about 60 secondary ICD-9-CM codes listed on most LCDs.  The LCD from Arizona, whose Medicare Administrative Contractor (MAC) is Noridian, separates these diagnoses into three categories. Category I generally requires short-term treatment (around 6-12 visits), while Category II generally requires moderate-term treatment (around 12-18 visits) and Category III may require long-term treatment (18-24 visits). I have chosen one cervical diagnosis from each category and investigated them below. Chiropractic practice primarily is concerned with disorders of the musculoskeletal and nervous systems, so most of the new codes will come from those ICD-10-CM chapters.

Category I

There are 16 ICD-9-CM codes listed in Category I. One of the most commonly used is 723.1, cervicalgia. It simply indicates “neck pain,” meaning it is not a very specific code. This is probably why it is considered “short-term” in the LCD. GEMs, which only give approximations, suggest M54.2. This new code has the same definition, so it seems like a pretty straightforward, one-to-one mapping.

There are a few details to consider, however. In ICD-9-CM, this code excludes conditions occurring due to inter-vertebral disc disorders; those are coded using the 722 series, which happen to be Category III codes. In other words, should such a disorder come into play, the Category III codes should be used instead, since Medicare recognizes that this type of neck pain may require treatment of a longer term.

There is another lesson to take away here as well. M54.2 in the ICD-10-CM code set has an “excludes 1” note regarding cervicalgia occurring due to inter-vertebral disc disorders (in M50._). “Excludes1” is a new convention used in ICD-10-CM. It tells us that these two codes may not be used together, for any purposes. If it were an “excludes2” notation, that would mean that the two conditions can co-exist, but both must be coded to report the situation.

Category II

These codes may indicate a moderate term of treatment. A commonly used code from this list of 36 codes is 847.0, neck sprain. The GEMs point to two codes in this instance:  S13.4xxA, sprain of ligaments of the cervical spine; and S13.8xxA, sprain of joints and ligaments of other parts of the neck. The difference is that the first code lists three specific ligaments, as well as whiplash injury. The other code covers anything else in the neck.

We see here that ICD-10-CM provides payers with a little more detail, since there is more than one code available to describe this condition. Medicare very well may replace the ICD-9-CM code with both of these ICD-10-CM codes. However, it may only choose to cover the first code. That is just part of the mystery.

There are a couple of ICD-10-CM coding convention lessons to learn here as well. These new codes contain seven characters, but the fifth and sixth characters are just marked “x,” because they are merely placeholders. In other words, they don’t add meaning to the code; they simply make sure the seventh character stays in the seventh position, where it is supposed to be.

The seventh character here could be either “A,” initial encounter, “D,” subsequent encounter, or “S,” sequela. So there are actually six possible codes. This ability to report on the status of an encounter is new in ICD-10-CM, and may be found on several codes that chiropractic physicians will use. It appears that the code will end with “A” on the first visit and “D” for follow-up. The “S” only would be used if the condition technically has been resolved, but the patient still is experiencing problems a long time later. I suspect that Medicare may not approve of the use of sequela codes since they may fit better under its definition of “maintenance care.”

Category III

There are only a dozen codes to choose from in this category, and they represent the most serious conditions. Patients with these conditions may require long-term treatment, according to the LCD. A commonly used ICD-9-CM code from this section is 722.4, degeneration of a cervical inter-vertebral disc. This includes the “cervicothoracic” region as well.

The GEMs lead us to M50.30, other cervical disc degeneration, unspecified cervical region. This is another great example of how GEMs can get us pointed in the right direction, but do not always take us all the way to the end of our journey. M50.30 is an “unspecified” code. One of the reasons ICD-10-CM exists is to keep providers from using “unspecified” codes. If we look a little closer we see that M50.31 specifies the occipito-atlanto-axial region, M50.32 specifies the mid-cervical region, and M50.33 specifies the cervicothoracic region.

It would be great if we could just figure out which codes will be approved based on GEMs, but in this example, again, we are led to an unspecified code. I suspect that Medicare likely will not cover M50.30, but the other three specified codes (M50.31 to M50.33) will appear on the new LCD. Thus, providers will have to indicate in their documentation that level of detail, which was not previously necessary.

Remember, these are only my speculations. As we get closer to the implementation date, more information likely will emerge, and we will be able to make better guesses. In the meantime, as we keep digging, we will continue to identify new issues and possibilities. At the very least, this should allow us to adapt with as little pain as possible.

Remember, these predictions are just for a few cervical diagnoses.

Next time we’ll investigate some lumbar issues.

Related article:

Which ICD-10-CM Codes Will Chiropractic Physicians Use to Bill Third Parties? - Part 1



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, 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.