Posts Tagged ICD-10-CM
By Evan M. Gwilliam, DC, CPC, CCPC, NCICS, CCCPC
Right now, it’s hard to say which ICD-10 codes third-party payers will select as medically necessary, but we can make an educated guess based on information from a few sources. For doctors of chiropractic (DCs), the natural place to start is with the relatively short list of frequently used ICD-9-CM codes for submitting claims. We’ll investigate a handful of diagnosis codes that Medicare recognizes as medically necessary and explore ICD-10-CM code possibilities.
Code the Primary Diagnoses in ICD-10-CM
Medicare administrative contractors (MACs) release local coverage determinations (LCDs) for chiropractic services. Most require the first diagnosis code to be selected from category 739 Nonallopathic lesions, not elsewhere classified. The ICD-9-CM definition of this code has long been a source of frustration to chiropractic coders because the documented phrase used by chiropractic physicians is usually “vertebral subluxation.” The fine print in ICD-9-CM explains that category 739 can include “segmental or somatic dysfunction.” But throughout ICD-9-CM, the term “subluxation” is used to describe a “partial dislocation,” which is not how the term is defined by many chiropractors. Medicare, by contrast, defines subluxation reasonably well on behalf of the chiropractic profession. Per the Medicare Learning Network Chiropractic Services booklet, page 7:
“A motion segment, in which alignment, movement integrity and/or physiological function of the spine are altered although contact between joint surfaces remains intact. For the purposes of Medicare, subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebra anatomically.”
Put more simply, subluxation is a condition of minor, sometimes painful, misalignment that is treatable by manipulation.
ICD-9-CM has never provided a code that differentiates between the chiropractic subluxation and the allopathic subluxation. Chiropractors have been compelled to try to fit a square peg into a round hole for many years. With its expanded detail, ICD-10-CM looks like a chiropractic coder’s dream. At first glance, ICD-10-CM offers a wide range of new possibilities.
If the general equivalence mappings (GEMs) are used as a starting point for this investigation, the commonly used ICD-9-CM code 739.1 Nonallopathic lesions; cervical region may be replaced with M99.01 Biomechanical lesions, segmental and somatic dysfunction of cervical region. This differs little from ICD-9-CM, and still does not use the word “subluxation.” Nearby code M99.11, however, is defined as “Subluxation complex (vertebral) of the cervical region.” This sounds just like the verbiage most chiropractors use, but the GEMs point this code back to 839.00 Closed dislocation, cervical vertebra, unspecified, not 739.1, in ICD-9-CM. Medicare does not allow 839.00.
Another possible replacement for the 739 codes can be found in chapter 19 (Injuries) of ICD-10-CM there are several appealing codes in the S13.11 Subluxation and dislocation of C0/C1 cervical vertebrae category. They are defined as “subluxation of cervical vertebrae.” The new codes provide information about the specific spinal level, whether it’s a subluxation or dislocation, and whether the encounter is the initial or a follow-up visit.
These codes not only use the word “subluxation,” they include detail that chiropractic physicians have never been able to report using ICD-9-CM. Unfortunately, GEMs point these codes back to the 839 category in ICD-9-CM, rather than to the 739 category. This implies that these new codes may be intended for use by allopathic physicians for dislocations, rather than for the chiropractic subluxation. No one has let chiropractic coders know if they should use M99.01, M99.11, S13.11xx, or something else.
Secondary Diagnoses: Use Category I, II, and III
According to the LCD for Arizona, whose MAC is Noridian, the secondary diagnosis selected by chiropractic physicians must come from a list of about 60 choices (see LCD for Chiropractic Services (L24288), the Centers for Medicare & Medicaid Services (CMS) Noridian Administrative Services, Feb. 27, 2012).
These ICD-9-CM codes are separated into three categories: Category I generally requires short-term treatment (approximately 6-12 visits); Category II generally requires moderate term treatment (approximately 12-18 visits); and Category III may require long-term treatment (approximately 18-24 visits). To demonstrate, one cervical diagnosis has been selected from each category to investigate. Chiropractic is primarily concerned with disorders of the musculoskeletal and nervous systems; therefore, the old and new codes come from those respective chapters in ICD-9-CM and ICD-10-CM.
There are 16 ICD-9-CM codes listed in this first category. One of the most commonly used is 723.1 Cervicalgia, or neck pain, which 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 Cervicalgia as the ICD-10-CM equivalent. This new code has the same definition, and seems like a straightforward one-to-one map.
There are a few details to consider, however. In ICD-9-CM, this code excludes conditions due to intervertebral disc disorders. Those are coded using the 722 Intervertebral disc disorders series, which are Category III codes. In other words, if the GEMs hold true and this specific diagnosis applies, a Category III code should be used instead because Medicare recognizes this type of neck pain may require longer-term treatment.
There is another lesson here. Code M54.2 in ICD-10-CM has an “Excludes1” note regarding cervicalgia due to intervertebral disc disorders (in M50.xx). “Excludes1” is a new convention in ICD-10-CM that tells us these two codes may not be used together, ever. If it were an “Excludes2,” the two conditions can co-exist, but both must be coded to adequately report the situation.
These codes may require a moderate term of treatment. A commonly used code from this list of 36 codes is 847.0 Sprain of neck. The GEMs point to two ICD-10-CM codes in this instance: S13.4xxA Sprain of ligaments of the cervical spine, initial encounter and S13.8xxA Sprain of joints and ligaments of other parts of the neck, initial encounter. The difference is the first code lists three specific ligaments, as well as whiplash injury. The other code covers anything else in the neck. ICD-10-CM provides payers with a little more detail because there is now more than one code to describe this condition. Medicare may likely replace the ICD-9-CM code with both of these ICD-10-CM codes; however, they 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 here, as well. The new codes contain seven characters, but the fifth and sixth are “x” because they are placeholders. They don’t add meaning to the code; they simply make sure the seventh character stays in the seventh position, where it’s supposed to be.
The seventh character here could be “A” for initial encounter, “D” for subsequent encounter, or “S” for sequela. As such, there are actually six possible codes. This ability to report on the status of the encounter is new in ICD-10-CM, and may be found on several codes that chiropractic physicians may use. The code will end with the letter “A” on the first visit and “D” for follow-up. You would use “S” only if the condition has technically resolved, but the patient is still experiencing problems a long time later.
Medicare may not approve of sequela codes because they fit better with its definition of “maintenance care.”
There are only a dozen codes to choose from in this section, and they are the most serious. Patients with these conditions may require long-term treatment, per many Medicare LCDs. A commonly used ICD-9-CM code from this section is 722.4 Degeneration of a cervical intervertebral disc, which also includes the “cervicothoracic” region.
As an equivalent to this code, GEMs lead us to M50.30 Other cervical disc degeneration, unspecified cervical region. This is another example of how GEMs point the coder in the right direction, but do not take him or her all the way to the end of the journey. M50.30 is an “unspecified” code. One reason that ICD-10-CM exists is to keep providers from using unspecified codes. M50.31 Other cervical disc degeneration, occipito-atlanto-axial region specifies the occipito-atlanto-axial region; M50.32 Other cervical disc degeneration, mid-cervical region specifies the mid-cervical region; and M50.33 Other cervical disc degeneration, cervicothoracic region specifies the cervicothoracic region.
It would be great if GEMs simply provided the code that will be approved when ICD-10-CM is finally implemented, but in this example, the result is an unspecified code. It’s likely Medicare will not cover M50.30. It’s reasonable to guess the other three specified codes (M50.31, M50.32, and M50.33) will appear as part of an updated LCD when ICD-10-CM arrives, and providers will have to indicate that level of detail in their documentation, which was not necessary previously.
Stay Tuned as ICD-10-CM Approaches
Because 95 percent of the ICD-10-CM codes do not map one-to-one, the new list will look very different. Selection of the correct codes will depend on the payer, not GEMs. Payers will have to rewrite their guidelines around the new codes. For now, coders and providers must simply do their best to get familiar with the new system and make calculated guesses.
Chirocode. 2011. Complete & Easy ICD-10 Coding For Chiropractic, First Edition
Noridian, Medicare LCD for Arizona, L24288, Chiropractic
Medicare Learning Network, October 2011. Chiropractic Services (ICN 906143)
Evan M. Gwilliam, DC, CPC, NCICS, CCPC, CCCPC, is the director of education and consulting for the ChiroCode Institute. He teaches seminars around the country on behalf of Cross Country Education and Target Coding, serves on the editorial board of ICD10Monitor.com, and he will be speaking on ICD-10 at the American Chiropractic Association’s National Legislative Conference this year. You can see Dr. Gwilliam at the “Anatomy Expo” and hear him speak at the AAPC National Conference in April on “Coding Secrets in Physical Medicine.” Dr. Gwilliam can be reached at DrG@ChiroCode.com.
April 1st, 2013
Marilyn Tavenner, administrator of the Centers for Medicare & Medicaid Services (CMS), announced there will be no delay to implementation for ICD-10-CM and PCS, which is scheduled October 1, 2014. She then encouraged everyone in the industry to work diligently toward a successful transition.
Tavenner made the statement at the annual Health Information Management Systems Society (HIMSS) conference, a year after she announced a 90-day comment period to determine if and how long a delay would be. The comments at that time ranged from killing ICD-10 completely to making no change from the originally planned date of 2013. Ultimately, the implementation was postponed by a year. Many providers and payers are using the extra year to better prepare.
Several organizations hoped Tavenner might announce another postponement at the HIMSS gathering, and some still advocated shelving the code set, but it looks like implementation is a done deal.
March 21st, 2013
Walk through real cases to help you strengthen A&P.
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC
Preparing for ICD-10-CM implementation requires a strategy to minimize productivity losses. Remember how painfully slow it was to search the ICD-9-CM codebook when you first started to learn coding? Although ICD-10-CM may be familiar to you (if you are well versed in ICD-9-CM), the educational bar has been raised. To remain productive, coders need a good understanding of anatomy and pathophysiology (A&P), as they relate to clinical specificity in ICD-10-CM.
Physicians do not write in coding terms; they document for the patient’s clinical condition. The clinical terms do not match up entirely with the coding descriptors—meaning that you need to be able to uncover the pertinent information and assign codes appropriately.
Do Your Skills Measure Up?
Will you be able to interpret the clinical documentation? Or will you be constantly searching and querying your provider? Worse yet, will you just assign unspecified codes? Answering yes to either of the latter two questions will cost you. Either your provider will question your ability to code, the practice will lose revenue by using unspecified codes, or both.
To assess your readiness, review these clinical documentation examples and then choose the correct ICD-10-CM code.
Case No. 1: Debilitating Migraine
Subjective: Patient complains of intermittent headaches. He has had similar headaches for eight years. He comes in now because the headaches used to occur 3-4 times a year, and now they are occurring 3-4 times a month. The headaches are so severe that he is unable to work. He describes them as a throbbing pain behind his right eye. The headaches are often accompanied with nausea, and in the last few months he has occasionally vomited during an episode. Light aggravates his symptoms, but he has no associated visual symptoms.
Objective: His neurologic exam is unremarkable.
Assessment: Chronic migraine
ICD-10-CM choices for chronic migraine:
G43.701 Chronic migraine without aura, not intractable, with status migrainosus
G43.709 Chronic migraine without aura, not intractable, without status migrainosus
To figure out which code is correct, you must know the answer to these questions:
What is an aura?
What is the definition of intractable, or status migrainosus?
Here’s some help:
An aura is a physiological warning sign that a migraine is about to begin. Migraines with auras occur in about 20-30 percent of migraine sufferers. An aura can occur one hour before the attack of pain and last for 15-60 minutes. The symptoms always last less than an hour. Visual auras include:
- Bright flashing dots or lights
- Blind spots
- Distorted vision
- Temporary vision loss
- Wavy or jagged lines
Auras also can affect the other senses. These auras may be described simply as having a “funny feeling,” or the person may not be able to describe the aura. Other auras may include ringing in the ears or changes in smell, taste, or touch.
Status migrainosus refers to a rare and severe type of migraine that can last 72 hours or longer. The pain and nausea are so intense that people who have this type of headache often need to be hospitalized. Certain medications, or medication withdrawal, can cause this type of migraine syndrome.
Intractable headaches are those that don’t respond to medications or therapy, and require intervention outside of the standards.
In this case, the patient has had the condition for eight years, and it has gotten progressively worse. Light bothers the patient, but he has no visual impairments. There is no note that medications are not working, or that the headaches last longer than 72 hours. Based on this information, we can assign code G43.709.
Case No. 2: Coronary Heart Disease, Myocardial Infarction
A second, more complex example requires multiple diagnosis codes:
Chief complaint: CAD, MI.
History of present illness: An 85-year-old male, new patient who has a history of coronary artery disease with previous myocardial infarction and inducible monomorphic ventricular tachycardia. He has a dual chamber cardio defibrillator model and a dual chamber cardioverter with an atrial lead. He presents for evaluation of a recent myocardial infarction and inducible monomorphic ventricular tachycardia. He was walking in his house when suddenly, without warning, his device fired. He had no symptoms of palpitations or heart racing prior to the event. He felt the same before and after the event, aside from anxiety related to shock. His device was interrogated and demonstrated the shock occurred for atrial fibrillation with a rapid ventricular response. This resulted in slowing of his ventricular response, but did not convert him from his chronic atrial fibrillation. As a result of this shock, his Inderal® has been increased from 80 mg once daily to 120 mg daily. He does not notice any difference in the increased dose of Inderal®. He has no symptoms of chest pain or angina. He has mild symptoms of exertional dyspnea and NYHD Class II symptoms, but no symptoms of rest dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema.
Medications: Medicines were reviewed and include Inderal® LA – 120 mg daily, Cozaar® – 25 mg daily, aspirin – 325 mg daily, a multivitamin – one daily, and valium – as needed.
Examination: Vital signs: Pulse 78 bpm and irregular; blood pressure 118/74; respirations 16; height 5′ 6″; weight 165 lbs.
Cardiovascular: The cardiac apex is not displaced. The first and second heart sounds are normal. There is a grade systolic murmur of mitral insufficiency. The JVP is normal at 3 cm. The carotids have normal upstrokes without bruits.
Respiratory: The chest expands normally. There is good air entry to both bases. No adventitious sounds are heard.
Laboratory data: His device was evaluated and his battery voltage is currently 2.64 volts with a replacement indicator at 2.62 volts. His atrial fibrillation is noted with a ventricular response about 80 bpm. An echocardiogram from Aug. 21, 2009, showed a dilated left atrium at 4.9 cm. His left ventricular function was normal with an ejection fraction of 60 percent.
Impression: 1) ICD shock secondary to paroxysmal atrial fibrillation with rapid ventricular response. 2) Normal functioning cardioverter defibrillator – nearing end of life. 3) Ventricular tachycardia. 4) Coronary artery disease. 5) lschemic cardiomyopathy – EF 60 percent, NYHD class II. 6) Hypertension. 7) Allergy to ACE inhibitors.
Recommendations: This gentleman received an implantable cardiac defibrillator shock because of a rapid response from his underlying atrial fibrillation. He recently had his beta blocker dose increased, but his ventricular response is still somewhat rapid. I have recommended he increase his Inderal® to Inderal LA® 80 mg twice daily. If hypotension ensues, lowering his dose of Cozaar® would be appropriate. His CHADS2 score is only one; therefore, I would continue with aspirin for his anticoagulation. It is interesting to note that the defibrillator shock did not convert his atrial fibrillation to sinus again, supporting the idea that this is chronic atrial fibrillation. He should have his defibrillator changed when he reaches an elective replacement indicator of 2.6 volts. I will be pleased to change out his device at the appropriate time. I hope this letter is useful to you in the management of this patient.
I48.0 Paroxysmal atrial fibrillation
I47.2 Tachycardia, ventricular
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.5 Cardiomyopathy, ischemic
I25.2 Old myocardial infarction
Z88.8 History, personal, allergy, other drugs, medicaments, and biologic substances
Here are some pathophysiology elements you need to understand to tie in the proper coding:
Coronary heart disease (CHD), also called coronary artery disease (CAD), is a condition in which plaque builds up inside the coronary arteries. It is the most common type of heart disease. The coronary arteries supply oxygen-rich blood to the heart muscle. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. When plaque builds up in the arteries, the condition is called atherosclerosis. The buildup of plaque occurs over many years.
A common symptom of CHD is angina. Angina is chest pain or discomfort that occurs if an area of your heart muscle doesn’t get enough oxygen-rich blood. Angina may feel like pressure or squeezing in your chest. You also may feel it in your shoulders, arms, neck, jaw, or back, and it may even feel like indigestion. The pain tends to get worse with activity and goes away with rest. Emotional stress also can trigger the pain.
Another common symptom of CHD is shortness of breath. This symptom happens if CHD causes heart failure. In the event of heart failure, the heart can’t pump enough blood to meet the body’s needs.
ICD-10-CM separates codes for ischemic heart disease by the type of vessel affected, and whether the patient is also experiencing angina.
Heart failure is coded by the type, such as systolic, diastolic, or a combination of both, as well as whether the condition is acute or chronic.
Systolic heart failure is a form of heart failure in which the heart’s lower chambers (ventricles) have become too weak to contract and pump out enough blood to meet the body’s needs, resulting in shortness of breath and other heart failure symptoms.
Diastolic heart failure is defined as symptoms of heart failure in a patient with preserved left ventricular function. A stiff left ventricle often is characterized with decreased compliance and impaired relaxation, which leads to increased end diastolic pressure.
The patient in this example has multiple diagnoses. He is diagnosed with paroxysmal atrial fibrillation, ventricular tachycardia, and CAD with no mention of previous coronary artery bypass graft (CABG); therefore, it’s coded as a native artery. There is no mention of angina, ischemic cardiomyopathy, hypertension (which is not described as due to heart disease), or history of myocardial infarction (MI). He also has an allergy to angiotensin-converting-enzyme (ACE) inhibitors.
Without a working knowledge of A&P, these two examples may have taken you quite awhile to look up everything necessary to make the appropriate code selections. By preparing now with a solid A&P course, you will be more effective in your coding, and worry less about productivity losses with the new coding system.
Rhonda Buckholtz, CPC, CPMA, CPCI, is vice president of ICD-10 Training and Education at AAPC.
March 1st, 2013
This month’s A&P spotlight is on the heart. With each heartbeat, blood is sent throughout our bodies, carrying oxygen and nutrients to all of our cells. We are going to take a look at this amazing muscle along with some common conditions and how they will look in ICD-10-CM. Without a strong understanding of the anatomy of the heart, coders will struggle to assign the correct codes in ICD-10-CM.
The heart is the pumping station of the cardiovascular system. It is often referred to as the hardest working muscle in the human body. It sits between the lungs and behind the sternum. It is a fist-sized, cone-shaped muscle that beats nearly 115,000 times per day at an average rate of 80 times a minute. The heart has four chambers: the atria (two upper chambers) and the ventricles (two lower chambers). Left ventricular hypertrophy (LVH) is an enlargement of the left ventricle and may be due to several different things. The most common cause is high blood pressure. LVH increases the risk of myocardial infarction, stroke, and death. In ICD-10-CM, the code for left ventricular hypertrophy is I51.7 Cardiomegaly.
The heart is divided into right and left sides by a septum (a muscular wall). While in utero, there is normally an opening between the atria to allow blood to flow around the lungs. The right and left ventricles are also not separated. If the walls don’t completely form by birth, the holes are considered septal defects. Ventricular septal defect is one of the most common congenital heart defects. These are congenital conditions; therefore, they are located in Chapter 17 of ICD-10-CM. Code Q21.0 denotes a ventricular septal defect and Q21.1 denotes an atrial septal defect.
The heart also has four valves: tricuspid, mitral, pulmonary, and aortic. These valves are fibrous cusps that help the flow of blood throughout the heart by opening to permit blood flow and closing to prevent backflow of blood. The chordae tendineae are tendons made up mostly of collagen that link the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae tendineae (sometimes called the heart strings) transmit the resulting increase and decrease in tension to the respective valves, causing them to open and close. Examples of ICD-10-CM codes for these conditions include: I34.2 Nonrheumatic mitral (valve) stenosis, I35.2 Nonrheumatic aortic (valve) stenosis and insufficiency, and I07.1 Rheumatic tricuspid insufficiency. There are also combination codes if multiple valves are diseased. For example, I08.2 Rheumatic disorders of both aortic and tricuspid valves.
This is just the “tip of the iceberg” for the cardiovascular system. In coming newsletters, we will revisit this system and delve deeper. The more you understand the structure and function of the organ systems, the more efficient and secure you will be in your coding in ICD-10-CM.
January 9th, 2013
With the implementation of ICD-10-CM, coding for fractures will require an in-depth knowledge of the patient’s course of treatment. ICD-10-CM will require more precise location choices, laterality, episode of care, and indication as to the healing process of the fracture. ICD-10-CM indicates that a fracture not indicated as open or closed should be coded to closed (which is the same as ICD-9-CM currently reads). ICD-10-CM also indicates that a fracture not indicated whether displaced or non-displaced should be coded to displaced (ICD-9-CM does not specifically state this).
7th character extenders are utilized for fracture code assignment in ICD-10-CM to indicate the encounter. The encounter denotes where the patient is in the treatment cycle: initial, subsequent, or sequel (late effect). In some cases there are 16 choices for the 7th character extenders for a fracture. When you look at the choices in detail, you can see that it is a major improvement to the process of coding the patient’s diagnosis. For instance, when coding for traumatic fractures, the initial visit by the provider will require the “initial encounter” 7th character extender to indicate the patient is receiving active medical treatment for their condition:
A – initial encounter for closed fracture
B – initial encounter for open fracture type I or II initial encounter for open fracture NOS
C – initial encounter for open fracture type IIIA, IIIB, or IIIC
Initial encounters include first visits, evaluation by a new provider, and surgical intervention.
When the patient returns for subsequent visits, it will be necessary to indicate his or her healing process with the appropriate 7th character, including:
D – subsequent encounter for closed fracture with routine healing
F – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
H – subsequent encounter for open fracture type I or II with delayed healing
K – subsequent encounter for closed fracture with nonunion
R – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
These 7th character extenders are used to indicate the patient has completed active medical treatment and is receiving routine care during the healing or recovery phase. The 7th character extender S is used to indicate a sequela, or late effect has occurred.
While code assignment for fractures may take a little longer with ICD-10-CM, more precise, detailed code assignment will lead to faster claim adjudication and fewer record requests.
November 14th, 2012
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