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ICD-10 Possibilities for Chiropractic Physicians
By Evan M. Gwilliam
The ChiroCode Institute and the American Chiropractic Association (ACA) merged forces last year by combining the Chiro- Code DeskBook with ACA’s Chiropractic Coding and Compliance Manual. This marriage was the result of a very long and cautious courtship. However, the relationship simply makes sense in terms of ensuring a universal standard for the profession to follow in the sometimes contentious and ambiguous field of coding and compliance. In March 2013, ACA held its National Chiropractic Legislative Conference (NCLC) in Washington, D.C. As the director of education for the Chiro- Code Institute, I was invited to speak at the NCLC educational symposium on the subject of ICD-10 preparation. The experience was somewhat different from that at my usual seminars.
When I arrived at the Capitol Hilton, just two blocks from the White House, I scanned the program to see how my presentation appeared. The program simply said “ICD9-10.” I was disappointed to see there were no catchy phrases or scare tactics included to frighten the doctors into attending. The other session scheduled at the same time was titled, “Concussion and Youth Sports”—pretty stiff competition. It’s tough to get doctors excited about learning coding.
Indeed, chiropractic physicians, much like other providers or specialists, have buried their heads in the sand in regard to the impending coding change. ICD-10 is not mandatory until Oct. 1, 2014. Therefore, I expected to find myself speaking to a near empty room. As I began, there were actually only a handful of physicians, but as people finished their lunches, they began to stream in, and by the end of my presentation the room was nearly full.
Reducing ICD-10 Anxiety
I like to survey my audience members to find out what their perceptions are. I explain to them that my goal is to reduce their ICD-10 anxiety by at least 50 percent. Before we began, nearly everyone had a negative perception and felt that ICD- 10 was going to be a real pain.
My presentation reviews the history and limitations of ICD-9, and then the structure of ICD- 10. My goal is to help attendees see that ICD-10 really is better and that the hassle is worth it. I then introduce cross-walking common ICD-9 codes for DCs, starting with general equivalence mappings (GEMs), followed by deeper research. It is important for people in workshops to have tools to use for follow-up. Two years ago, the ChiroCode Institute released a book entitled, Complete and Easy ICD-10 Coding for Chiropractic. It is the basis for most of my chiro-centric information and a great resource if you want to take the next step beyond this article. The last piece of my presentation is focused on implementation steps, which include budget considerations, cross-walking, forms, vendor relationships and internal testing.
In the end, I believe my purpose was fulfilled: A few more DCs have reduced their ICD-10 anxiety, and know what they need to do to get ready. There is plenty more to do, and more information is forthcoming, but the first steps have been laid out. Here is a sneak peek at what you will be facing as you prepare to transition to ICD-10.
Medically Necessary Codes
No one really knows which ICD-10 codes will be selected as “medically necessary.” However, we can make an educated guess. We simply start with the relatively short list of ICD-9 codes that are frequently used by DCs. We will examine a few commonly used lumbar diagnosis codes. By exploring the ICD-10 options, we can learn a lot about the key differences with ICD-9.
In the examples here, I start with the GEMs, written by the National Center for Health Statistics (NCHS), which is basically a crosswalk from ICD-9 to ICD-10. Unfortunately, it provides only approximations. This approach may be useful for those attempting to create their own internal crosswalk for their clinics as they begin to prepare for ICD-10 implementation in October 2014. (Some companies, like Find-A-Code, have created a free app with the complete GEMs database for smartphones and iPads. This is a great tool to get you started on your own crosswalk.)
Lumbar Spine Codes and Excludes1
The ICD-9 codes selected for research here are from the lumbar spine. They are 724.2 lumbago, 724.4 thoracic or lumbosacral neuritis or radiculitis unspecified, and 724.3 sciatica. Based upon my research with the information available to providers at this time, I think these are fairly reasonable guesses to be labeled medically necessary.
724.2 lumbago is a Category I code on many Medicare local coverage determinations (LCDs); that is, Medicare recognizes it as requiring only 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 should only be used when a more descriptive code from 720-724 is not available. GEMs takes us to M54.5 low back pain, loin pain and lumbago NOS. This definition is slightly different from the old code, but the interesting fact is that this code has an “Excludes1” note. Excludes1 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 care than mere low-back pain. In the past, physicians might have been content to use 724.2, but greater detail is necessary to code for ICD-10. In this case, that greater detail can mean accurate reimbursement 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 many Medicare LCDs. This means that Medicare recognizes that it may require 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 from 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 the result of an autoimmune disorder. Radiculitis, which is more consistent with “medically necessary” chiropractic care, results from swelling due to trauma to the nerves.
The mapping of this code to ICD-10 is a good example of why the ICD-10 code set is so much larger than the 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 are “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 Excludes1 codes. They are primarily combination codes that include radiculopathy in their definitions along with a more descriptive cause, such as spondylosis.
724.3 sciatica, neuralgia or neuritis of the sciatic nerve, is a code used to describe a condition treated quite frequently in the chiropractic office. It falls into Medicare’s Category III, which may require long-term treatment. The other codes in this category are severe neurological and structural diagnoses. Sciatica is characterized by sharp shooting pain or numbness and muscle weakness from the low back down the rear of one leg. It is usually the result of pressure on the nerve from a herniated disc.
The GEMs crosswalk leads to M54.30 sciatica, unspecified side. The word “unspecified” is a red flag, because it will most likely be excluded from the list of codes that many payers recognize as “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 must now specify right- or left-sided sciatica with M54.31 and M54.32. In fact, just a little farther down the page in the ICD-10 book 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.
As you work through the codes you use in your office, you will learn about the key differences between ICD-9 and ICD-10. Once Medicare and other payers finally release the codes they will approve for claim submission, these articles will have to be rewritten. For now, you have my best guesses. I hope they have helped ease your mind about what lies ahead as you prepare for the transition.
1. Noridian, Medicare LCD for Arizona, L24288, Chiropractic.
3. Chirocode Complete & Easy ICD-10 Coding for Chiropractic, First Edition, 2011.
Dr. Gwilliam is the director of education and consulting for the ACA Endorsed Partner ChiroCode Institute; he teaches seminars around the country on behalf of Cross Country Education and Target Coding and serves on the editorial board of ICD10Monitor.com. He can be contacted at DrG@ChiroCode.com.
Published in the June/July 2013 ACA News.