August 10th, 2015
There is a word that has long been held as sacred to the Chiropractic profession. It is the so-called vertebral “subluxation.” Throughout ICD-9, which is the diagnostic code set used on claims for the last thirty years, the term “subluxation” is used to describe a partial dislocation,” which is not how it is defined by many Chiropractors. Medicare defines it reasonably well on behalf of the chiropractic profession:
“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, it is a condition of minor, sometimes painful, misalignment that is treatable by manipulation. The ICD-9 definition is more in line with the “partial dislocation” view point, which is treated by Medical Doctors with things like medication. ICD-9 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. At first glance, it appears that ICD-10 is a Chiropractic coder’s dream. ICD-10 offers a wide range of new possibilities; however, the debate is still undecided.
Currently most Medicare Administrative Contractors require Chiropractic Physicians to use an ICD-9-CM code from the 739 category in position 1 of box 21 on the CMS-1500 claim form. This code range is defined by ICD-9-CM as a “Nonallopathic lesion, not elsewhere classified.” This definition is a far cry from the one taught by Chiropractic colleges. This description only says what it is not, rather than what it is. Fortunately the fine print that follows adds “segmental and somatic dysfunction.” This helps clarify it a little, but it is safe to assume that no Chiropractors were consulted when this definition was written.
According to General Equivalency Mapping (GEMs), (which is a crosswalk between ICD-9 and ICD-10 provided by the National Centers For Health Statistics-download a free app called “FindACode” to check your own ICD-10 codes), the commonly used ICD-9 code of 739.1 (Non-allopathic lesions; cervical region cervicothoracic region), may be replaced with M99.01, which is “segmental and somatic dysfunction of cervical region.” This differs little from ICD-9 and still does not use the word “subluxation.” However, nearby we find the code M99.11, which is defined as “subluxation complex (vertebral) of the cervical region.” This sounds just like the verbiage most chiropractors use, but the GEMs points this code back to 839.00, not 739.1, in ICD-9. This is the code for “closed dislocation, cervical vertebra, unspecified,” which is more fitting for medical conditions. It is not really geared towards the Chiropractic model.
In Chapter 19 of ICD-10 we find several appealing codes in the S13.11 category. They are defined as “subluxation of cervical vertebrae.” The new codes provide information about the specific spinal level, whether it is a subluxation or dislocation, and whether the encounter is the initial or a follow-up visit. Depending on how you look at it, there are more than 50 alternatives to the old 739.1 in this code range. This is detail that Chiropractic Physicians have never been able to report using ICD-9. Unfortunately, GEMs points these codes back to the 839 category again rather than the 739 category in ICD-9. This implies that these new codes may be intended for use by allopathic physicians for dislocations, rather than for the Chiropractic subluxation.
There are two more factors to consider: First, GEMs is only an approximation, and some judgment is required to select the codes that most accurately describe the situation. Mapping is rarely a 1-to-1 match, so these may not be the only options. Second, payers will have to determine which codes will properly document medical necessity, and this is the big mystery. Payers have their business rules encoded for ICD-9. No one has come forward to let Chiropractic coders know if they should use M99.01, M99.11, or S13.11xx, or something else. Will payers be able to apply old decision logic to these new codes? Chiropractic coders probably won’t find out until they submit the first claims after October 1st, 2014. They will just have to wait and hope that the subluxations they have been diagnosing all these years will finally be reportable with ICD-10.
By Evan Gwilliam, DC, CPC, CCPC, NCICS, CCCPC, CPC-I, MCS-P, CPMA
“Chiropractic Services” CMS.com.
Last modified October, 2011
Chirocode Complete & Easy ICD-10 Coding for Chiropractic
First Edition. Arizona: ChiroCode Institute, Inc., 2011.