by Evan M Wsilliam, DC, CPC, CCPC, NCICS, CCCPC, CPC-I, MCS-P, CPMA
September 11th, 2013
By Evan M. Gwilliam, DC, CPC, CCPC, NCICS, CCCPC, CPC-I, MCS-P, CPMA
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. More detail is expected from Medicare before the end of 2013. 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.
Primary Diagnoses in ICD-10-CM for DCs
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 yet 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 that 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 may 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. Its 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)