By Dr. Evan Gwilliam
Using a Medicare Local Coverage Determination (LCD), and the General Equivalence Mappings (GEMs) as a starting point, I will attempt in this article to predict which ICD-10-CM codes will be approved for the secondary cervical diagnoses which Medicare uses now. (By the way, I just use the free FindACode app on my iPad to look these up and you can do this too.)
Since Medicare sets the tone for other payers to follow, we can then hope that these 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), Category II generally require 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 is primarily concerned with disorders of the musculoskeletal and nervous systems, so most of the new codes will come from those ICD-10-CM chapters.
There are 16 ICD-9-CM codes listed. One of the most commonly used is 723.1, cervicalgia. It simply means "neck pain" and is not a very specific code. This is probably why it is considered "short term" in the LCD. General Equivalence Mappings (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 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 series, which happen to be category III codes. In other words, if this qualifies, the category III codes should be used instead, since Medicare recognizes that this type of neck pain may require longer term treatment.
There is another lesson here as well. M54.2 in the ICD-10- CM code set has an "excludes1" note regarding cervicalgia due to intervertebral disc disorders (in M50._). "Excludes1" is a new convention in ICD-10-CM. It tells us that these two codes may not be used together, ever. If it were an "excludes2", that would mean that the two conditions can co-exist, but both must be coded together 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, 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. The 847 code includes strain as well. In order to code for strain, one would need to look it up in the alphabetic index, which would lead you to S16.1xxA, which is strain of muscle, fascia and tendon at neck level.
We see that ICD-10-CM does provide payers with a little more detail since there is 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, at this point.
There are a couple of ICD-10-CM coding convention lessons here as well. These new codes contain seven characters, but the fifth and sixth are just "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 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 the 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 the letter "A" on the first visit and "D for follow up. The "S" would only be used if the condition has technically resolved, but the patient is still experiencing problems a long time later. I suspect that Medicare may not approve of sequela codes since they may fit better with their 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, according to the LCD. A commonly used ICD-9-CM code from this section is 722.4, degeneration of a cervical intervertebral disc. This includes the "cervicothoracic" region as well.
The GEMs leads us to M50.30, other cervical disc degeneration, unspecified cervical region. This is another great example of how GEMs just gets us pointed in the right direction, but does not take us all the way to the end of our journey. M50.30 is an "unspecified" code. One of the reasons that ICD-10-CM exists is to keep providers from using "unspecified" codes. If we look a little deeper, 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, we are led to an unspecified code. I suspect that Medicare will likely 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 that level of detail in their documentation, which was not necessary previously.
These are my speculations. As we get closer to the implementation date, additional information may come forward and we will be able to make more accurate guesses. In the meantime, as we keep digging, we will find new issues and possibilities. At the very least, it should allow us to adapt with as little pain as possible.
Chirocode Complete & Easy ICD-10 Coding For Chiropractic, Second Edition, 2013
About the Author
Dr. Evan Gwilliam holds seven different certifications related to coding, compliance, and audit. He is the Director of Education and Consulting for the ChiroCode Institute and performs chart audits for Chiropractors all around the country. He can be reached at DrG@ChiroCode.com
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