Imagine ICD-10 Coding Possibilities for Chiropractic Physicians

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.

Category I

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.

Category II

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.”

Category III

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.

References:

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

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Address Principal Procedure Reporting Quandaries

By Catrena Smith, CPC, CCS, CCS-P, PCS, HIT PRO-PW

March 26th, 2013

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ICD-10-CM: No Delay This Time

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

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Be an Effective Coding Compliance Professional: Do You Have What It Takes?

By Ida Landry, MBA, CPC

Knowing coding and billing rules, and following them with integrity, is key to success.

Compliance is an important part of medical coding. Novice coders are instructed early on that “correct coding is the No. 1 objective,” and “if it isn’t documented, it wasn’t done.” These rules of thumb are the backbone of compliant coding for all coders. To be an effective coding compliance professional, however, you must also stay current with coding and billing regulations and have a solid code of ethics.

Know How Compliance Fits into Today’s Coding and Billing

Payment is generated or denied by the guidelines, rules, and federal laws payers use to direct their part of the revenue cycle. In the past, payers acted as compliance overseers, but in recent years legislation like the Tax Relief and Health Care Act of 2006 and the Affordable Care Act of 2010 have mandated more oversight regarding documentation and coding compliance. An example of the reimbursement climate resulting from these regulations is increased scrutiny by recovery audit contractors (RACs). “From 2005 through 2008, the Medicare RACs identified and corrected over $1 billion in improper payments. The majority, or 96 percent, of the improper payments were overpayments, while the remaining 4 percent were underpayments,” according to the Federal Register, 2011, p. 57808.

A byproduct of increased oversight is the establishment of more compliance departments and restructuring in health care organizations to meet the growing need for proper coding and documentation.

Key Compliance Principles

To understand fully coding compliance and be an effective medical coding compliance professional, you must have a commitment to the core principles, rules, guidelines, and laws that embody medical compliance. This is the first objective to successfully mastering compliance elements. Another important element is adhering to a code of ethics and integrity.

These core elements can be realized through successful instruction, education, and guidance of compliant coding and documentation requirements.

Compliance Means Trust, Not Opinion

As a coding compliance professional, you should provide tangible information whenever you instruct another health care professional on appropriateness of coding or documentation. If established guidelines, specifications, and/or legislation cannot provide validation, than any guidance given is considered opinion.

Protect trust at all cost. When an opinion is given as fact and later proven to be incorrect, this is unprofessional and risky. Once trust is broken, your opinion as a coding compliance professional is no longer credible. This guidance is simple; however, there are instances in the coding community where trust is destroyed.

Trust also is abused when a compliance professional tells a coder one thing and the health care provider something different. This behavior can stem from provider pressure or a provider’s inability to comply with rules and guidelines. To prevent inconsistent information from being disseminated, present the same guidelines, rules, and regulations to all parties involved. Using information consistently also shows ethics and integrity. To maintain consistency throughout an organization, consider following a code of ethics.

Code of Ethics

AAPC has a code of ethics which addresses coding professionalism and compliance integrity. The eight components of AAPC’s Code of Ethics are:

• Maintain and enhance the dignity, status, integrity, competence, and standards of our profession.
• Respect the privacy of others and honor confidentiality.
• Strive to achieve the highest quality, effectiveness, and dignity in both the process and products of professional work.
• Advance the profession through continued professional development and education by acquiring and maintaining professional competence.
• Know and respect existing federal, state, and local laws, regulations, certifications, and licensing requirements applicable to professional work.
• Use only legal and ethical principles that reflect the profession’s core values, and report activity that is perceived to violate this Code of Ethics to the AAPC Ethics Committee.
• Accurately represent the credential(s) earned and the status of AAPC membership.
• Avoid actions and circumstances that may appear to compromise good business judgment or create a conflict between personal and professional interests.

Other places to look for a code of ethics are your compliance or coding departments. Human Resource departments also may assist you if your company has a written code of ethics.

Use Compliance Tools at Your Fingertips

You can easily find useful tools to help you attain your goals. Here is a list of some typical resources you use:

• Office of Inspector General (OIG) website – On the “Compliance Guidelines” page, there are links to “Compliance 101 and Provider Education” and “Compliance Resource Material,” as well as other useful tools.
• Coding books -  CPT® codebook, CPT® Assistant, ICD-9-CM, HCPCS Level II, AHA Coding Clinic for ICD-9, AHA Coding Clinic for HCPCS, OptumInsight’s™ Uniform Billing Editor, DRG Expert, and the AAPC website
• Government coding/billing resources – Centers for Medicare & Medicaid Services (CMS) manuals; National Coverage Determinations; Medlearn Matters; the Federal Register; 1995 and 1997 Documentation Guidelines for Evaluation and Management Services; Medicare administrative contractors, Local Coverage Determinations, etc.
• Freedom of Information Act – Used to request federal agency records not publicly available.
• Federal acts -  Health Insurance Portability and Accountability Act (HIPAA); Health Information Technology for Economic and Clinical Health (HITECH) Act; the Affordable Care Act; Tax Relief and Health Care Act of 2006; False Claims Act; Medicare Prescription Drug, Improvement, and Modernization Act of 2003; Stark law; anti-kickback statute, etc.
• Commercial payer resources – Look to company manuals, websites, webinars, and newsletters for guidance.
• Company compliance manuals – Your employer should be anxious to share its compliance manuals and plans with coding and billing staff.

Being a coding compliance professional is a noble profession with ethics and integrity, knowledge of documentation and coding guidelines, and trust and validation at the core of its foundation. If you think you have what it takes to be a coding compliance professional or are thinking about becoming certified, AAPC now offers the Certified Professional Compliance Officer (CPCO™) credential. Go to aapc.com for details on how to begin this exciting journey.

Ida Landry, MBA, CPC, works for CareOregon and has worked in the health care industry since 1995. She acquired CPC® certification in 2004. Ms. Landry holds a Bachelor of Science in Health Administration and a Master of Business Administration in Health Care Management. She enjoys teaching and sharing her knowledge of coding.

March 1st, 2013

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Be an Attractive Candidate for a Hospital Coding Position

By Dorothy Steed, CPA, CPC-H, CPC-I, CEMC, CFPC, CPMA, CHCC, CPUM, CPUR, CPHM, CCS-P, RCC, RMC

Be ready if a hospital employment opportunity arises in a facility near you.

In our changing health care environment, there may come a time when you need to look beyond your physician practice and branch out in another direction. For example, based on the latest trend, your practice could be bought out by a hospital. If that happens, you’ll need to be able to prove you’re a viable candidate to hospital coding managers. However, many physician trained coders find hospital requirements very different and the transition difficult. You’ll have a much easier time if you are prepared, and a good place to start is by reviewing the hospital revenue cycle, which has significant differences from that of the physician office.

Review the Hospital Revenue Cycle

There will be differences between facilities in regards to the revenue cycle, depending on the size of the facility and whether they are for profit or not for profit. Typically, however, the chief financial officer looks at the hospital’s revenue producing departments and establishes certain monetary monthly goals for that department using service utilization, patient flow, and other data. The chief revenue officer typically determines a positive or negative outcome for each revenue-producing department using various reporting programs. If a department has an income deficit, this prompts a close look at why the deficit has occurred. There can be many reasons, but if the department does not produce expected revenue, particularly if the deficit occurs frequently, the department’s management must give an accounting of why and how he or she plans to improve the deficit.

The revenue cycle starts in Patient Access and moves to Benefits Verification. These are critical steps in obtaining correct demographic information, determining whether services will be covered, and calculating patient responsibility amounts. Errors in these steps usually have a ripple effect. If the patient is admitted as an inpatient or into observation, typically, case management is responsible for monitoring the stay and determining if the stay meets inpatient criteria and (if a Medicare patient) whether there is adequate inpatient days to cover the stay. If an observation patient is converted to inpatient status by the physician, this group will advise Benefits Verification that new authorization for inpatient services is necessary.

Understand Your Role in the Hospital Revenue Cycle

The next step in making yourself marketable in the hospital environment is to determine your role in the revenue cycle. The health information management (HIM) manager ensures that attending physicians complete the patient records in a timely manner and records are ready for the coders. Here is where a physician trained coder must be ready to shift gears. Regardless of what you are initially hired to do, you must realize that at some point, you will need to code inpatient records. This is where the money is for hospitals, so inpatient records take priority over outpatient encounters, even if outpatient coding is your normal assignment. To prepare for this new assignment and to stand out as a candidate for inpatient coding:

• Be proactive in showing an interest in learning inpatient coding.
• Take time to look at inpatient records coded by inpatient coders.
• Realize that inpatient and outpatient coding guidelines are somewhat different.
• Become very knowledgeable about coding conventions and guidelines in the front of your ICD-9-CM coding book. This is how hospital coders are expected to code the records. Encoders that are structured for hospital use will also assign codes based on these conventions. National Correct Coding Initiative (NCCI) edits are included in the encoder and generally flag the coder to look closely at two reported codes. Coding Clinic and CPT® Assistant are normally sources available within the encoder.
• Understand that CPT® is not reported on inpatient records. Procedures are coded using ICD-9-CM Volume 3, and there is not a direct crosswalk between CPT® and Volume 3. To assign codes from Volume 3, ask yourself: Is the procedure surgical in nature? Does it carry a surgical or anesthetic risk? Does it require specialized training to perform the service? If your answer is yes to any of these questions, a code is assigned. Using this information, take a look at some familiar CPT® codes and determine how the service might be reported using Volume 3. A reasonable rule of thumb is that if CPT® describes multiple steps, often more than one code from Volume 3 must be used to report the same service.
• Know that hospital coders report all conditions that the physician manages or affect the management of the patient. Inpatient records may require 10, 15, or even 20 diagnosis codes.
• Realize that sometimes there are different reporting protocols in CPT®, depending on whether you report for physician or facility services—infusions are a good example. Review the reporting hierarchy for facility infusions in your CPT® codebook to see how they differ from physician reporting.
• Be aware that facility evaluation and management (E/M) reporting is captured only in the emergency department and in facility clinics. History, exam, and medical decision making (MDM) are not factors in facility E/M; levels are determined based on use of resources and assigned based on a point system. Each facility typically determines their own point system; however, the service must be documented in the medical record, meet medical necessity, and be reasonable in the point assignments. Look at outpatient modifiers 73, 74, and 27, used by facilities, and know when these modifiers are applicable.

Understand How Charge Description Masters Are Used

In assessing your qualifications, hospitals may also look at your knowledge of charge description masters (CDM). Facilities establish services in the CDM that are charged to the patient’s financial record and are entered usually by the department performing the service. Hospital coders typically code for all diagnosis coding, surgical procedures, and infusions. They may code for other services, depending on if the service  is already embedded in the CDM. Your coding manager will advise of these services, but typically drugs, supplies, laboratory, radiology, and anesthesia are not coded by the hospital coder. Some clinics, such as pain management, may charge through the CDM or be coded by a coder, depending on how the hospital handles these functions.

Another important thing to remember: The physician is not available to clarify documentation; and you will not be able to use charge tickets, encounter forms, or super bills for coding assistance.

Meet Productivity and Accuracy Standards

Accuracy and meeting quota also may factor into whether you are a good candidate for hospital coding. When the coding department experiences a backlog of records for coding, the manager must take action to bring the records current. This is a good example of when an outpatient coder may be asked to code inpatient records, and why hospital coders are held to productivity and accuracy standards. You will be held to these same productivity standards.

Although there may be slight differences, depending on expectations of the coding manager, typical coding time is approximately:

• Inpatient records: 18-20 minutes. This includes all diagnosis codes, Volume 3 codes, assigning the present on admission (POA) indicator, and abstraction of the record.
• Ambulatory surgery records: 7-10 per hour
• Emergency department records: 20 per hour
• Referral encounters (example: patients coming for lab, X-ray): 30 per hour

These numbers translate to three minutes for emergency department records and two minutes for referral encounters.

If you are given a pre-employment coding test, the coding manager will not only look at accuracy, but whether there is reasonable expectation you can reach these production standards by the end of the normal 90-day probationary period. When records are not coded quickly, the entire revenue cycle is affected, in billing, insurance follow up, and other collection efforts. Accounts receivable days are closely monitored by hospitals, and are a primary measure used to determine their financial health. Slowdowns and backlogs of the revenue cycle directly affect the revenue stream. Time spent collaborating with other coders must be kept to a minimum if you intend to meet your productivity requirements.

Seek Training

When I speak with physician coders about transitioning to hospitals I am asked, “Where can I obtain this type of training?” Here are some ideas that may be helpful:

• Invite someone from your hospital to present at a chapter meeting. If a coding professional is not available, use someone from the billing or revenue cycle department.
• If there is a community college in your area that has a HIM program, invite someone from that program to speak at a chapter meeting.
• Use Quality Improvement Organizations (QIO) as a resource. They review disputes between Medicare and hospitals about correct Medicare Severity Diagnosis Related Groups (MS-DRG) assignments and necessity of inpatient admissions. They may send coding disputes to a contracted coder for supporting opinions, but they have already done an in-house review prior to that step.
• If you have a hospital-based member in your chapter, ask that person to help you get training underway.

Interested in implementing physician-to-hospital coder training in your chapter? Based on the three-day workshops I present, training might begin with an overview of hospital coding and billing on day one. On days two and three, activities might include hands-on coding of sample hospital records—reviewing accuracy and looking at how quickly coders can determine codes and POA indicators. Consider holding sessions on three consecutive days or on three separate Saturdays. Something else to consider: This is a good opportunity to collaborate with another chapter to arrange a group session.

Sell Yourself Using Knowledge and Adaptability

Through my experience when speaking with hospital managers about an ideal candidate, they often mention the need for coders to be able to code multiple types of records, meet productivity standards, and be familiar with hospital encoders. You may not have an opportunity to use encoders unless you are actually in a hospital, but you can focus on building efficiency in multiple encounters, being open minded, and knowing that you will need to meet productivity standards.

Take advantage of opportunities to learn the facility side of coding. Realize hospitals provide many more services than physician offices. If general surgery is your specialty, it’s likely you’ll need to code for many other types of services. Hospitals in smaller towns may be more lenient when using a physician coder, but you should still sell yourself in an interview by showing you are ready for the challenge. If you welcome the opportunity and are proactive in learning about the facility world, doors that are not easily opened will open for you.

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