by Melinna Giannini
August 10th, 2015
This article is coming out before the payers have told us which ICD-10 codes will be used for claim submission. However, we have access to the same code set that they do, therefore this is an educated guess at which codes might used by DCs for the lumbar spine. The ICD-9 codes selected as a starting point are taken from the Medicare Local Coverage Determination (LCD) for Arizona, whose Medicare Administrative Contractor (MAC) is Noridian. Though the General Equivalence Mappings (GEMs), written by the National Center for Health Statistics (NCHS), are only approximations, it will be used as a starting point for cross walking from ICD-9 to ICD-10. This approach may be useful for those attempting to create your own internal implementation in October 2014. (By the way, I just use the free FindACode.com 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 my predictions will apply to private payers as well. Based upon the information available to providers at this time, I think these are fairly reasonable guesses.
The Medicare LCD for Chiropractic places diagnosis codes into three categories, with progressively longer treatment times. I have chosen one code from each category to investigate here. They are 724.2 lumbago, 724.4 thoracic or lumbosacral neuritis or radiculitis unspecified, and 724.3 sciatica.
724.2 lumbago is a Category I code on the LCD; that is, Medicare recognizes it as only requiring a short term of treatment. This code is very general and does not provide much information about the cause of the back pain. The ICD-9 description includes the words “low back pain, low back syndrome, and lumbalgia” as well. It should only be used when a more descriptive code from 720-724 is not available. GEMs takes us to M54.5 low back pain, loin pain, and lumbago NOS. This definition is slightly different from the old code, but the interesting fact is that this code has an Excludes1 note. Excludes1 is a new convention in ICD-10. It means that the excluded codes should never be coded at the same time as the code above the note. These include S39.012 low back strain, M51.2- lumbago due to intervertebral disc displacement, and M54.4- lumbago with sciatica. It is important to note that these conditions are more serious and usually warrant more care than mere low back pain. In the past physicians may have been content to use 724.2, but greater detail is necessary to code for ICD-10. In this case, that greater detail can mean more income by documenting the need for a longer duration of care.
724.4 thoracic or lumbosacral neuritis or radiculitis unspecified, is a Category II code on the Medicare LCD. This means that Medicare recognizes that it may require a moderate term of treatment. In ICD-9, the definition also includes “radicular syndrome of the lower limbs”. In these two conditions the patient suffers from severe pain, burning, or tingling sensations in one or both legs and it worsens with movement. The cause of neuritis is unknown, but it is thought to be caused by an auto-immune disorder. Radiculitis, which is more consistent with Chiropractic care, results from swelling due to trauma to the nerves.
The mapping of this code to ICD-10 is a good example of why the ICD-10 code set is so much larger than ICD-9. We go from one code to four. GEMs takes us to M54.14, M54.15, M54.16, and M54.17. These four codes are “radiculopathy” followed by the specific region of the lower spine. Coders must know their spinal anatomy well in order to select the correct code. The category M54.1 also lists four Excludes1 codes. They are primarily combination codes which include radiculopathy in their definitions along with a more descriptive cause, such as spondylosis. The ICD-10 Medicare LCD will likely list all four codes from GEMs as well as most of these Excludes1 codes in place of this single ICD-9 code.
724.3 sciatica, neuralgia or neuritis of the sciatic nerve, is a code used to describe a condition treated quite frequently in the Chiropractic office. It falls into Medicare’s Category III, which may require long term treatment. The other codes in this category are severe neurological and structural diagnoses. Sciatica is characterized by sharp shooting pain or numbness and muscle weakness from the low back down the rear of one leg. It is usually the result of pressure on the nerve from a herniated disc. In ICD-9, this code excludes more specific lesions of the sciatic nerve from 355.0, which are frequently traumatic. The 355 code is not a covered diagnosis by Medicare for Chiropractic physicians.
The GEMs crosswalk leads to M54.30 sciatica, unspecified side. The word “unspecified” is a red flag because it will likely be excluded from the list of codes that Medicare recognizes as medically necessary reasons for Chiropractic treatment. Fortunately the writers of ICD-10 were well aware that ICD-9 lacked codes that differentiated laterality. Hence, physicians must now specify right or left sided sciatica with M54.31 and M54.32. In fact, just little farther down the page in ICD-10, there are codes for right and left sciatica with lumbago (M54.41 and M54.42). This is a nice example of a combination code that was not available at all in ICD-9. All of these codes will probably be added to the Medicare LCD.
Medicare has assured us that an LCD listing the ICD-10 codes they will use will be available by April 10, 2014 at the latest. We won’t begin to use them on claims until October 1, 2014, but CMS is planning to accept test claims sometime in March. In other words, more details are forthcoming, so stay tuned.
Noridian, Medicare LCD for Arizona, L24288, Chiropractic
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