An ICD-10 Ode to Rudolph

December 11th, 2015
Codes, ICD-10

Your old favorite, with a new twist.

Rudolph the Red-Nosed Reindeer (W55.31XA Bitten by other hoof stock, initial encounter),
Had a very shiny nose (Q30.8, Other congenital malformations of nose).
And if you ever saw it (H53.60, Unspecified night blindness),
You would even say it glows (T67.9XXA, Effect of heat and light, unspecified, initial encounter).

All of the other reindeer (W55.89XA, Other contact with other mammals, initial encounter)
Used to laugh and call him names (R45.81, Low self-esteem).
They never let poor Rudolph
Join in any reindeer games (Z60.4, Social exclusion and rejection).

Then one foggy Christmas Eve (T69.9XXA, Effect of reduced temperature, unspecified, initial encounter),
Santa came to say (R47.81, Slurred speech),
“Rudolph, with your nose so bright,
Won’t you guide my sleigh tonight (V80.791A, Occupant of animal-drawn vehicle injured in collision with other nonmotor vehicles, initial encounter)?”

Then how all the reindeer loved him (R00.2, Palpitations),
As they shouted out with glee (H93.13, Tinnitus, bilateral),
“Rudolph the Red-Nosed Reindeer,
You’ll go down in history (Z86.59, Personal history of other mental and behavioral disorders).”


ICD-10 Talk with Dr. Heidi Jannenga: How Many ICD-10 Codes Do I Really Need to Know?

November 6th, 2015
Codes, ICD-10, ICD-9, Insurance

Overwhelmed by the sheer size of the ICD-10 code set? Not to worry. As Dr. Heidi Jannenga explains in this edition of ICD-10 Talk, rehab therapy practitioners definitely don’t need to know every single code. In fact, they likely will stick to a few key subsets of codes. Which ones, you ask? Watch this video to find out, and stay tuned to ICD10forPT.com for all the latest ICD-10 news.



ICD-10 FAQ Part 4

November 6th, 2015
Codes, ICD-10, Transition

A few months ago, we started receiving tons of questions about the switch to ICD-10. So many questions that we quickly put together our first ICD-10 FAQ post, which we thought was the best darned thing ever (hence the title). But there was no satisfying your need for speed—er, answers. In fact, your questions about the code set switch started coming in even faster (unlike the healthcare industry’s transition to ICD-10, which was the slowest thing ever). Clearly, the impending coding change had folks feeling more than a little anxious, so we compiled a second and a third FAQ post. Even now, as ICD-9 (Tokyo) drifts further and further away, we’re still receiving tons of questions. Here are the answers to your most-pressing ICD-10 questions—for now, anyway:

Where do I find information on state regulations related to ICD-10?

We suggest contacting your payers, as well as consulting your state association’s website/state practice act, to get the most up-to-date, state-specific information.

What’s the difference between R53.1, Weakness, and M62.81, Muscle weakness (generalized)?

According to this resource, M62.81 is typically classified as a disorder characterized by a reduction in the strength of muscles in multiple anatomic sites, or a reduction in the strength of muscles in multiple anatomic sites. R53.1, on the other hand, is a sign or symptom associated with:

  • weakness and diminished or absent energy and strength;
  • debility, or lack or loss of strength and energy;
  • physical weakness, lack of strength and vitality, or a lack of concentration;
  • lack of physical or mental strength;
  • liability to failure under pressure or stress or strain;
  • weakness; and/or
  • lack of energy and strength.

If I shouldn’t use unspecified codes, then why are they even an option?

The unspecified codes exist in case there truly is not another, more specific option available. However, if a more specific option is available, you absolutely should use it.

If a patient experiences muscle weakness in a specific area, should I use M62.81?

The clinical description for M62.81 reads, “A disorder characterized by a reduction in the strength of muscles in multiple anatomic sites.” Because this code describes weakness in multiple anatomic sites, it would not be appropriate for weakness that exists in a specific location. As mentioned in our other FAQs, if available, you should always code for the underlying condition causing the muscle weakness first.

Can I list a condition like poor balance as a primary diagnosis?

You should code first for the underlying condition (i.e., what’s causing the patient’s balance issues). If you can’t determine the underlying condition, ICD-10 code R26.81, Unsteadiness on feet, might be a good option.

What code should I use for difficulty walking? R26.2 or R26.89?

Depending on your evaluation, you might discover the reason behind the disordered movement is best described by one code more than the other. Each code has its own synonyms that can help you make your selection.

For example, this resource explains that the description synonyms for R26.2, difficulty walking are:

  • Difficulty walking
  • Walking disability

The description synonyms for R26.89, Other abnormalities of gait, and mobility are:

  • Cautious gait
  • Gait disorder due to weakness
  • Gait disorder, painful gait
  • Gait disorder, weakness
  • Gait disorder, postural instability
  • Gait disorder, multifactorial
  • Toe walking and toe-walking gait
  • Limping/limping child

Should I code for accidents/incidents that affected my patients in the past?

You cannot—and should not—code for what you don’t know. If you can’t say for certain that the accident/incident directly correlates to the patient’s current condition, don’t code for it.

What if I have a highly-specific clinical coding question, and I can’t find the answer?

We’re happy to answer your questions to the best of our abilities. However, if the example is extremely clinical in nature, we can’t give you a definitive answer. But, we do know of a resource exactly for these types of situations. If you are able to supply supporting documentation for your particular scenario, you can submit your coding questions via this AHA portal.

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We’re more than a month into the so-far-so-good transition, but we expect the questions to keep coming faster and furious-er (um, yeah—something like that). And that’s OK. We’ve got you covered. Fast five, anyone?


ICD-10 FAQ Part Three

October 23rd, 2015
Codes, ICD-10, ICD-9, Insurance, Transition

We know that lots of good things come in threes—like three-piece suits, the Three Stooges, the three French hens your true love gave to you, and the number of sheets to the wind you might be after happy hour. And now, that list includes our ICD-10 FAQ series. In our first two pieces (here and here), we covered a lot of ground and—hopefully—gave you a good mid-level understanding of ICD-10. This third installment dives into the nuances of using the new code set to help you address some of your trickiest questions. So, let’s get to it:

General Questions

Does my treatment diagnosis have to match the diagnosis the referring physician sent? Sometimes my physicians don’t send codes with their referrals.

Your treatment diagnosis doesn’t necessarily have to match your referring physician’s diagnosis. With ICD-9, therapists typically used only the treatment diagnosis codes, leaving off the “true” diagnosis codes (i.e., medical diagnosis codes), because insurance companies only required treatment diagnosis codes for payment.

As the healthcare system shifts into a pay-for-performance environment—and with the introduction of alternative payment models—providers now must focus more on the complexity of the patient. And as far as claims go, the only way providers can communicate that complexity is through diagnosis codes. So, with ICD-10, it’s critical to include not only the treatment diagnosis codes, but also the codes for the medical diagnosis and comorbidities. This allows you to paint a complete, accurate, and detailed picture of the patient and his or her situation. Remember, though, that the primary code will still be your treatment diagnosis.

Thus, if your referring physician did not send a medical diagnosis, I would suggest reaching out to obtain one, as that will help ensure you code as thoroughly as possible.

When I get scripts with very generic instructions (e.g., “treat the legs”), is it okay for me to use an equally generic code (e.g., R29.9, Unspecified symptoms and signs involving the nervous and musculoskeletal systems)?

When you use generic—or in ICD-10 language, “unspecified”—codes, you risk payers inferring that your services are not medically necessary. So, it’s really up to you as to whether you’re willing to take that risk. We recommend either:

  1. reaching out to the referring physician to get more detail, or
  2. referring the patient to another specialist if, based on your clinical judgment, you believe the patient needs further evaluation that falls outside of your scope of practice.

In the ICD-10 code set, some codes have a dash ( – ) at the end of them. What does this mean?

The dash often is used in the note sections (e.g., Excludes1, Excludes2, and Code also). It indicates that the note applies to all of the codes in that series. That way, the codes don’t have to be listed out individually, which would take up a lot of space. So, to give an example, “T79.A-” would cover every single code that begins with “T79.A.”

Specific Coding Questions

How do I code for “X” patient with “Y” condition?

We’ve received numerous questions about how to code in very specific patient scenarios. However, because ICD-10 places such a strong emphasis on clinical judgment—which requires you, as the therapist, to select the most complete, accurate, and specific code(s) possible based on your assessment of the patient—we cannot provide coding advice for those scenarios. But, if you are able to provide supporting documentation, you can submit specific coding questions to this AHA portal.

What code(s) should I use to indicate decreased range of motion (ROM)?

While there are no codes for decreased ROM specifically, there are plenty of other codes that would apply to patients experiencing this symptom. For example, if a patient presents with decreased ROM in the knee, applicable codes may include those for difficulty walking or gait abnormality (R26.2 or R26.89), knee pain (M25.561 or M25.562), knee stiffness (M25.661 or M25.662), or knee effusion (M25.461 or M25.462).

I’m having trouble finding specific codes for conditions affecting the lumbar region (e.g., lumbar stiffness or decreased ROM in the lumbar spine). What are your suggestions?

While we are not trained coders, we can say that with ICD-10, you are encouraged to first code for the underlying condition causing such spinal symptoms. Here are a few resources that may help with coding spinal conditions:

What codes should I use to indicate muscle weakness in a specific anatomic location? The only muscle weakness code I can find is M62.81.

If the patient is experiencing weakness in one specific area, then the code for generalized muscle weakness (M62.81) likely would not be appropriate, as it indicates the weakness is present throughout the body. To code for weakness in a specific area, use the appropriate atrophy code (you’ll find many of these codes in the M62.5 code family). Additionally, keep in mind that the coding guidelines encourage you to code first for the underlying cause of the weakness, rather than the weakness itself. If you are able to do that, you can include the atrophy codes as secondary.

What ICD-10 code would you recommend for stiffness of the lumbar spine?

Whenever possible, you should first code for the underlying condition that is causing the symptom (which in this case is stiffness). Here is a resource that lists ICD-10 codes for common spinal conditions. As a secondary code, you could use M25.60, Stiffness of unspecified joint, not elsewhere classified (keep in mind that there is not a spine-specific option in that family of codes).

How do I code for impaired balance?

While there is not an ICD-10 code for impaired balance, there are several options that provide a much higher degree of specificity. These include the codes listed in the R26 (Abnormalities of gait and mobility) and R27 (Other lack of coordination) series. To select the code that best describes the patient’s condition, you’ll need to use your clinical judgment. You also may need to reference the coding synonyms provided in resources like this one.

Can I submit M54.5 (Low back pain) as a single, primary code?

Yes, M54.5 is a complete, billable code, and thus, you can use it as the primary. However, because it’s not a very specific code, you should only use it as the patient’s primary diagnosis code if there’s not a more specific code available to accurately describe the patient’s condition. If the patient has a confirmed underlying diagnosis (i.e., the condition actually causing the back pain), then you should code for that first. If not, then make sure you explain those details in your documentation.

I thought that the only seventh character options were A, D, and S, but I’ve noticed some codes have additional options (G, K, P, etc.). Is this a different seventh character system?

Yes. Codes for fractures use a whole different set of seventh characters:

  • A: Initial encounter for fracture
  • D: Subsequent encounter for fracture with routine healing
  • G: Subsequent encounter for fracture with delayed healing
  • K: Subsequent encounter for fracture with nonunion
  • P: Subsequent encounter for fracture with malunion
  • S: Sequela

You can learn more about fracture coding in ICD-10 here.  

External Cause Codes

If a patient doesn’t know what caused his or her injury, or if there’s no evidence that a specific event (e.g., a past car accident) resulted in the patient’s current condition, then do I need to use external cause codes?

You cannot code for what you don’t know. So, if you don’t know what caused the patient’s injury—or if there’s no definitive correlation between a known causal event and the patient’s current condition—then don’t code for it. Remember, external cause codes (like those that denote accidents) are optional. Just make sure you accurately record any potentially relevant information within the patient’s documentation.

I heard that S codes (i.e., injury codes) and M codes (i.e., musculoskeletal codes) cannot stand alone. What should I do if I don’t know any of the details necessary to select external cause codes (cause, location, activity, etc.)?

There is no blanket instruction regarding M codes and S codes being unable to stand alone. While you are encouraged to submit external cause codes when possible, they are not required. And if you do not know the details necessary to select those codes, then you shouldn’t submit them (in other words, you cannot—and should not—code for what you don’t know). However, you may see notes at the top of specific code categories instructing you to submit additional diagnosis codes with the codes in those particular sections (e.g., “Code also” or “Code first”).

The official ICD-10 coding guidelines state that external cause status codes, activity codes, and place of occurrence codes are “used only once, at the initial encounter for treatment.” Does that mean you only submit these codes on the claim for your initial evaluation of the patient?

Yes, according to the guidelines, you only need to submit those codes once, and that’s at the patient’s initial encounter (i.e., you initial evaluation). However, we have yet to see what will happen if those codes are submitted on subsequent claims. Different payers may have different rules, and some may enforce them more strictly than others. We don’t anticipate claims being denied for having “extra” codes; that said, if and when ICD-10-related denials start to occur, we’ll keep our Blog readers informed on the most common reasons behind those denials.

The above-cited coding guidelines excerpt seems to conflict with the excerpt that reads, “Assign the external cause code, with the appropriate 7th character (initial encounter, subsequent encounter or sequela) for each encounter for which the injury or condition is being treated.” I’m confused; should I submit external cause codes at every visit or just at the first visit?

Although Chapter 20 of the ICD-10 code set is titled “External Causes of Morbidity,” this chapter actually contains four different types of codes:

  1. place of occurrence codes,
  2. activity codes,
  3. external cause status codes, and
  4. external cause codes.

So, while you should report the main external cause code at every encounter, you only need to report the other types of codes at the initial encounter. Furthermore, “When applicable, place of occurrence, activity, and external cause status codes are sequenced after the main external cause code(s). Regardless of the number of external cause codes assigned, there should be only one place of occurrence code, one activity code, and one external cause status code assigned to an encounter.”

My billing system limits the number of codes I can submit. If I cannot submit all of the external cause codes that apply to a particular patient, how should I choose the one(s) I do submit?

Per the official reporting guidelines, “If the reporting format limits the number of external cause codes that can be used in reporting clinical data, report the code for the cause/intent most related to the principal diagnosis.”

Aftercare Codes

Should I always use an aftercare code for post-op patients?

Per the official ICD-10 coding guidelines (which you can find here), “The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th character ‘D’ (subsequent encounter).” Based on those guidelines, if the surgery resulted from an injury that allows for the seventh character, you would use the original acute injury code with the seventh character “D.”

What is the difference between the aftercare codes Z48.89 (Encounter for other specified aftercare) and Z47.89 (Encounter for other orthopedic aftercare)?

Z48.89 applies to all types of surgical aftercare, whereas Z47.89 applies to orthopedic procedures specifically.

Can I submit a post-surgical aftercare code (e.g., Z51.89, Encounter for other specified aftercare) as the patient’s primary diagnosis code?

Your treatment diagnosis should be the one that best supports the medical necessity of your therapy services, and if you submit more than one treatment diagnosis code, you should order them according to significance. The ICD-10 coding guidelines seem to suggest that the order may change based on the specific context of the patient’s situation. The guidelines read: “Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter.” In other words, it’s up to you (and your clinical judgment) to determine which code best represents the main reason the patient needs therapy treatment.

If I am providing post-surgical rehab therapy treatment, and the patient’s original condition (i.e., the one that prompted the surgery) is no longer present, which codes can I submit besides the aftercare code?

If the condition that caused the patient to undergo surgery no longer exists, then you should not code for it. Instead, you can submit any applicable pain/symptom codes relevant to the patient’s treatment. Ultimately, the codes you use, and the order in which you submit them, are up to you and your clinical judgment. Just make sure your documentation clearly supports your coding choices.

Considering the degree of specificity ICD-10 affords, it seems strange that there are not surgical aftercare codes for specific surgeries (e.g., rotator cuff repair or ACL repair). How, then, should I code for these post-op patients?

While there is not an aftercare code for every single surgery, in many cases, the proper way to designate the phase of treatment (i.e., indicate that the patient is receiving aftercare) is to code for the original acute injury and add the appropriate seventh character (which in this case, would be D). So, if, for example, the patient originally strained his or her right rotator cuff, you would indicate that you are providing aftercare by using the code S46.011D, Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, subsequent encounter. For more information on coding for aftercare, check out this blog post.

Claims

If I submit multiple diagnosis codes on a single claim, which one should I point to on my service lines?

You can submit up to four diagnosis code pointers per service line, which means you can point to up to four diagnoses.

If I have to resubmit a claim for a date of service prior to October 1, 2015 (meaning the claim contains ICD-9 codes), do I need to change the codes to ICD-10?

Because the transition to ICD-10 goes by date of service—not the date of claim submission—you should continue using ICD-9 codes for all claims with dates of service on or before September 30.

We bill electronically, and it is my understanding that we should be able to submit up to 12 diagnosis codes per claim. However, my billing software only sends the four top codes through to the claim. Why is that?

Because the standard HCFA claim form allows space for only four diagnosis pointers per service line, some billing systems only pull the four most relevant diagnosis codes through to Box 21 on the claim form. Those codes then become the origins for the four diagnosis code pointers that appear in Box 24E. We recommend looking for a billing system that allows you to send up to 12 codes through to Box 21; however, regardless of whether your system limits the number of diagnosis codes you can submit, it’s crucial that you order your codes according to significance, with those codes that most strongly support the medical necessity of your treatment appearing first.

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If ICD-10 is keeping you up at night, this post should help give you the guidance you need to get a few more hours of shut-eye. But, if our third ICD-10 FAQ wasn’t quite the charm, posit your ponderances to us using the form below, and we’ll do our darndest to answer them.


How ICD-10 Affects Your Claims

September 25th, 2015
CMS-1500, Codes, ICD-10, Insurance, Transition

There’s no doubt that the ICD-10 transition requires a huge shift in processes. But it’s not only your coding methodology that’ll change; your claims are going to look a little different as well. Here’s how ICD-10 affects your claims:

HCFA Forms are Ready

Wondering whether your beloved CMS 1500 forms are ready for ICD-10? Good news: the form was updated several years ago to account for ICD-10. This “new” form allows for up to 12 diagnosis codes—and you might just need all of those spots to accurately and completely describe a patient’s condition.

CPT Codes will Stick Around

If you’re an outpatient provider who uses CPT codes, you won’t need to change your procedural coding. You’ll continue to bill for the services you provide using the same codes you do now (e.g., 97001, 97110, and 97140). However, keep in mind that if you use superbills, you will need to update those to include ICD-10 codes. Finally, ICD-10 won’t impact the way you currently use any CPT-related modifiers (like KX or modifier 59).

One Service Line Allows for Four Codes

Remember the 12 available spots on the new HCFA forms? While you can submit up to 12 diagnosis codes on a single claim form, only four of those will map to a specific CPT code. That’s because the form only contains four diagnosis pointers per line. This is something that won’t change with the ICD-10 transition. Still, it’s important to include as many codes as you believe are relevant to your treatment.

Code Order Matters

When you’re dealing with multiple codes, you want to list them in order of importance. The first-listed code will be your primary code, which means it’s the code that most strongly supports the medical necessity of your treatment. Proving medical necessity is crucial when it comes to ICD-10; check out this blog post to learn more.

There’s no Minimum Number of Codes

For a claim to process correctly, it must contain at least one code. The number of additional codes you include is up to you. If you, as the clinical expert, believe one code accurately and fully describes a patient’s condition, then by all means, submit only one code. Beyond that, there’s no minimum of codes required on each claim.

Dual-Coding is a No-No

The transition to ICD-10 is determined by date of service. That means all claims with dates of service on or before September 30 must contain only ICD-9 codes, whereas all claims with dates of service on or after October 1 must contain only ICD-10 codes. The two can never appear together on the same claim. So, in order to avoid a dual-coding disaster, you may need to split your claims. Each payer will have its own claim-splitting requirements, so it’s important to check with that payer first before you determine how you’ll separate claims that span the transition date.

That said, some non-HIPAA-covered entities (e.g., workers’ compensation, and auto insurance) may not make the transition. So, you’ll need to continue to submit ICD-9 codes on the claims for those payers. We strongly suggest contacting your non-HIPAA covered payers individually to verify whether they plan to make the transition. Furthermore, as Lauren Milligan explains in this blog post, “Sometimes, you’ll see patients whose primary and secondary insurances require different code sets. In these cases, because you should include only ICD-9 codes on claims for payers who did not make the switch to ICD-10, you’ll need to split the claim and send each piece to the appropriate payer.”

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With these details in mind, give yourself a head-start by getting caught up on all of your billing prior to October 1. It may not be the easiest task, but it’ll save you a lot of headaches as you tackle the transition. And although not much will change in terms of how you complete and submit claims, you’ll be plenty busy adjusting your processes elsewhere. With the transition right around the corner, what are you doing to prepare?


A to Z: What you Need to Know About ICD-10 Aftercare Codes

September 22nd, 2015
Codes, ICD-10, ICD-10 Example, ICD-9

At this point in your ICD-10 journey, it’s likely you’ve noticed that the letters A through Z are no longer reserved for the tiny noodles floating in your favorite childhood soup. In fact, when it comes to ICD-10 coding, you could say that your payments hinge on selecting the correct letter. In ICD-10, letters can indicate a number of things about your patient’s condition, including the category of codes and the phase of treatment. Although this coding logic might not offer you the comfort that alphabet soup once did, these letters of designation do have their place. In terms of ICD-10, Z is just as important as A. But unlike the ABC song, the letter Z doesn’t signify the end. In fact, it signifies the beginning for some rehab therapists—namely, those coding for aftercare. Here’s what you need to know about Z codes—no slurping required:

“Goodbye” to the V57 series

The V57 code series you once knew (and loved) is saying sayonara, as this series isn’t included in the ICD-10-CM code set. If you were to map every one of these V57 codes to a relevant ICD-10 code, you’d end up with one match: Z51.90, Encounter for other specified aftercare. According to the ICD-10 tabular list, this code isn’t able to stand on its own; you also must code for the condition requiring care. Coding for the underlying condition helps prove the medical necessity of your treatment. For more on coding for medical necessity, check out this blog post.

“Hello” to the Seventh Character

If you have the option of submitting a primary diagnosis code that contains a seventh character on your claim, you should take that route rather than selecting one of the aftercare codes. The seventh character indicates phase of treatment, but not all codes require—or allow for—this character. Most of the codes within the musculoskeletal chapter of the tabular list (chapter 13) don’t allow for seventh characters. That’s because most of these conditions result from a healed injury or are chronic in nature—so the phase of treatment is already implied. As for those codes that do require seventh characters (like the ones that appear in chapter 19, also known as the injury chapter): By selecting “D” as the seventh character, you’re indicating that the patient is in the healing and recovery phase of treatment. And if you’ve added a primary diagnosis code with a “D” in the seventh character position, there’s no need to submit an aftercare code, because you’ve already indicated that the patient is in the healing and recovery phase of treatment.

“Maybe” to Z Codes for Surgical Aftercare

Postoperative care aims to bring a patient back to his or her healthy level of function. If you’re specifically providing a patient with surgical aftercare treatment, ICD-10 has a few coding options. To give a couple of examples, you can use Z51.89, Encounter for other specified aftercare, or Z47.1, Aftercare following joint replacement surgery. According to the official ICD-10-CM guidelines for coding and reporting, “Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter.” That said, your clinical judgement and documentation will justify your code selection.

“Sometimes” to Singular Coding

If you’ve selected a Z code as your primary code, it doesn’t necessarily mean you should ditch any additional codes. If there are other codes that apply to your treatment and the patient’s situation, you should include them as well. In some cases, this might mean submitting multiple Z codes to more fully describe the patient’s situation. According to this ICD10 Monitor article, “Aftercare codes should be used in conjunction with other aftercare codes, diagnosis codes and/or other categories of Z-codes to provide better detail on the specifics of the aftercare encounter/visit, unless otherwise directed by the classification.”

One good example of this is in surgical aftercare for a joint replacement. As explained in this WebPT blog post: “If you were treating a patient who had a total knee replacement, you would want to submit Z47.1, Aftercare following joint replacement surgery, as well as ICD-10: Z96.651, Status (post), organ replacement, by artificial or mechanical device or prosthesis of, joint, knee-see presence of knee joint implant.” In this example, the patient received surgery for osteoarthritis relief. It’s assumed the patient is not seeking treatment for osteoarthritis, as he or she has undergone surgery to remedy this condition. Thus, you would use both Z codes to indicate the surgery as well as the joint replaced. For more information on this scenario, check out the blog post.

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The use of aftercare codes might not be as cut and dried as you’d like to think. However, that doesn’t mean it needs to be a cause for concern. Just keep in mind that listing Z codes as primary codes should be a last resort. In fact, it may not be appropriate at all. If you have a code that more accurately describes why the patient is seeking therapy, apply that one. While ICD-10 coding might not be as enjoyable as singing your “ABCs” or chowing on some alphabet soup, I hope you’ll still find some satisfaction in knowing how—and when—to apply those oh-so-important letters.


The Best Darn ICD-10 FAQ for PTs

September 14th, 2015
CMS-1500, Codes, ICD-10, ICD-10 Delay, ICD-10 Example, ICD-9, Preparation, Transition

If you’re a HIPAA-covered medical professional, ICD-10 is a huge deal for you—like, deflategate huge. Along with all the controversy—including delays and grace periods—ICD-10 also has caused a lot of confusion. Over the course of the months leading up to the October 1 transition, we’ve received thousands of questions regarding the new code set. After sifting through your coding queries, we’d bet good money that thousands more folks have questions, but they’re afraid to ask. That’s why we gathered our very best answers to your most-frequently-asked questions and created this hefty, Costco-sized collection:

The Seventh Character Craze

What is the seventh character?

The seventh character didn’t exist in ICD-9, so it’s caused a great deal of confusion. Basically, it’s a mechanism for applying greater specificity to a diagnosis, particularly with regard to the episode of care. As its name would suggest, the seventh character should always be the seventh digit of a code. As this blog post details, there are three seventh characters related to the episode of care:

  • A (initial encounter) describes the entire period in which a patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause.
  • D (subsequent encounter) describes any encounter after the active phase of treatment, which is when the patient is receiving routine care for the injury during the period of healing or recovery.
  • S (sequela) indicates a complication or condition that arises as a direct result of an injury.

How do I know when to use the seventh character?

You don’t always need to attach a seventh character to your diagnosis code. Seventh characters are required for codes in certain ICD-10-CM categories—primarily Chapter 19 (Injury, poisoning and certain other consequences of external causes) and Chapter 15 (Pregnancy, childbirth and the puerperium). You’ll know when to use it because there will be instructions specifying seventh character use within any code book or tabular list you reference. Don’t see instructions? Then “leave the seventh position blank,” explains this blog post. “Adding a seventh character to a code that does not require one will make the entire code invalid.”

What’s the difference between A (initial) and D (subsequent)?

We’ve seen multiple interpretations of what distinguishes an “initial encounter” from a “subsequent encounter.” Based on everything we’ve reviewed, this is the best answer we’ve found: “The 7th character for ‘initial encounter’ is not limited solely to the very first encounter for a new condition. This 7th character can be used for multiple encounters as long as the patient continues to receive active treatment for the condition.” This resource goes on to say: “The key to assignment of the 7th character for initial encounter is whether the patient is still receiving active treatment for that condition.”

So, it appears that the words “initial” and “subsequent” have less to do with how many practitioners the patient has already seen or how many visits the patient has logged at your office, and more to do with the patient’s treatment phase (i.e., “A” for active treatment and “D” for recovery/healing). That would mean the “A” designation wouldn’t be limited to the patient’s first visit, even though the label “initial encounter” makes it seem like a one-time descriptor.

What about sequela (S)?

According to Code It Right Online, “‘sequela’ in ICD-10-CM, is a chronic or residual condition that is a complication of an acute condition that occurs after the acute phase of a disease, illness or injury. It can also be caused indirectly by the treatment for the disease or condition.” There’s no time limit on when you can use sequela; “the residual condition may come directly after the disease or condition, or years later.” Simply put, this less frequently-used character is reserved for complications or conditions directly resulting from an injury.

For further insight on sequelae, check out this example from the AAPC: “A patient suffers a low back injury that heals on its own. The patient isn’t seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury. Such a visit may be reported as G89.21 Chronic pain due to trauma and S39.002S Unspecified injury of muscle, fascia and tendon of lower back, sequela.” One caveat to this example: Don’t fall back on an unspecified code. Instead, ask the patient as many questions as possible to get to the root cause of the original injury.

How do I format a code that requires a seventh character?

As this post explains, “If you add a seventh character to a code with fewer than six characters, you must fill each empty slot with a placeholder ‘X.’” For example:

  1. You choose S44.11, Injury of median nerve at upper arm level, right arm, for your patient.
  2. You look at the instructions for the S44 code category and determine that you must add a seventh character to this code.
  3. Because the patient is receiving routine care for the injury in the healing and recovery phase, you determine that D is the appropriate seventh character.
  4. S44.11 is only five characters long, so you add an X in the sixth position.
  5. You then add your seventh character of D, making the final diagnosis code: S44.11XD, Injury of median nerve at upper arm level, right arm, subsequent encounter.

Do I need to change the seventh character every time a patient returns for another visit?

Nope. You would only change the seventh character if the patient progressed to a different phase of treatment (i.e., the patient moved from the active treatment phase to the recovery/healing phase).

External Cause Codes

Do I have to use external cause codes?

As explained in this blog post, there’s no national requirement mandating any provider—PTs included—to submit external cause codes. However, providers are encouraged to do so when possible. Most of the PT-relevant codes that allow for external cause codes are located in Chapter 19 of the tabular list (which you can access here). Furthermore, some state and regional payers may require the use of external cause codes, so check with each one individually.

What are external cause codes? And how do I use them?

Found in Chapter 20, external cause codes help give context to a particular diagnosis code, and contrary to the name, external cause codes can indicate more than cause. To appropriately apply accurate external cause codes, you’ll also have to consider the place of occurrence, activity, etc. We recommend asking yourself the following questions regarding the patient’s injury: How did the injury or condition happen? Where did it happen? What was the patient doing when it happened? Was it intentional or unintentional?

When do I use external cause codes?

If it’s possible to submit external cause codes for a particular category or section of codes, you will see instructions to do so within the tabular list. Also, bear in mind that you can never submit an external cause code by itself; it always must have a corresponding principal diagnosis code. Here’s a quick clip to show you how to use external cause codes.

What if I don’t know what caused a patient’s injury or condition?

External cause codes are not mandatory (at least not nationally). Remember: you cannot code for what you don’t know. So, if you don’t know the details necessary to select external cause codes—like what caused the onset of the injury, the activity the patient was engaged in at the time of the injury, or where the patient was when the injury occurred—then don’t submit any such codes.

The Great Switch

Should I start using ICD-10 codes now?

Short answer: No.

Long answer: Nooooooooooooo.

Payers will deny claims that contain ICD-10 codes prior to October 1, just like they’ll deny claims that contain ICD-9 codes after September 30.

What do I do about patients with visits spanning the transition date?

We’ve written an entire blog post on what to do prior to September 30 and after October 1, including specific to-dos for that 48-hour transition window. You can check it out here.

Do I need to complete a progress note, evaluation, or re-evaluation to switch to ICD-10 codes?

No. Instead, when it comes time to add ICD-10 codes for the patients who previously had ICD-9, you’ll simply update the diagnoses in the patients’ charts as they come in for appointments on or after October 1.

Will I need to mass-update my patient notes come October 1?

No, there’s no need for a sweeping code change for all your patient notes. You’ll simply update codes within patients’ charts as they come in for their visits.

What about the ICD-10 grace period?

There’s a lot of confusion regarding CMS’s “grace period.” According to CMS, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.” That means ICD-10 absolutely is happening on October 1. You’ll still receive denials from your commercial payers if you code inaccurately. And, for Medicare claims, you still have to code using valid codes from the accurate code family. For all of the details on what this grace period means for providers, check out this blog post.

The Resources

Where can I get an ICD-10 code book?

You can access the entire code set free of charge here. However, you may find a PT-specific ICD-10 code book useful for educational purposes, as it likely will provide guidance around coding strategy and processes. You can purchase it here.

Where can I find the tabular list?

You can download the tabular list here.

Is there an ICD-10 cheat sheet for physical therapists?

We have a wealth of educational resources that you can download here. However, we wouldn’t recommend using a “cheat sheet.” As most providers know, certain CPT codes are only payable when used in conjunction with certain ICD-9 codes. Thus, you may be tempted to quickly crosswalk those ICD-9 codes and tack up a new reimbursement cheat sheet—or worse, download the first cheat sheet you find online. Don’t. The rules aren’t the same, and crosswalks typically yield unspecified ICD-10 equivalents. As this ICD-10 for PT article explains, “One of the main battle cries of the new code set is increased specificity, and the transition to ICD-10 represents a giant step away from the use of unspecified codes (unless one of those codes truly represents the most accurate description of a patient’s condition). Thus, if you submit an unspecified code when a more specific code is, in fact, available, you could put yourself at risk for claim denial.”

Do you have any ICD-10 information specific to hand therapy?

We recommend checking out this ASHT page.

Do you have any ICD-10 information specific to pelvic health?

We recommend checking out this resource.

Claims, Claims, Claims

How do I handle billing for services provided before and after October 1?

We recommend that practitioners finalize notes and get claims submitted for all dates of service prior to September 30 before October 1 hits. That way, you’re able to start with as clean of a slate as possible come October 1. For additional info on dual coding, check out this post.

Are the 1500 forms going to change? How many ICD-10 codes will be allowed on the 1500 form, and how should I order them?

HCFA 1500 forms were updated in 2013 to accommodate ICD-10, so you shouldn’t have any problems there. You can list up to 12 ICD-10 codes. Keep in mind, though, that only the first four can be linked to CPT codes. Thus, it’s imperative that you arrange the ICD-10 codes in order of importance, with the codes that best justify the medical necessity of your services appearing at the top.

How will ICD-10 affect CPT codes (e.g., 97001, 97110, and 97140)?

ICD-10 does have a set of procedure codes, but anyone who currently uses CPT codes to designate procedures will continue to do so. So, if you’re using CPT codes, ICD-10 will not change that. You can continue using CPT codes as you do now, even after October 1.

Compliance

How does ICD-10 work with therapy cap exception codes?

There haven’t been therapy cap exceptions for a while now. In 2014, Medicare introduced a two-tier exceptions process. In the first tier, which is the Automatic Exceptions tier, therapists affix the KX modifier to necessary services provided above the cap amount. To learn more about the therapy cap, check out this guide.

How does ICD-10 affect the KX modifier?

It doesn’t. You will continue using the KX modifier to denote automatic exceptions in the same way you currently use this modifier.

Will ICD-10 affect G-codes?

ICD-10 will not affect functional limitation reporting (a.k.a. G-code reporting). The current rules will still apply after October 1.

Documentation

How do I handle direct access patients in ICD-10?

We’ve received tons of questions about how to choose the most accurate diagnosis codes for non-referral patients. For advice at every stage of the entire code selection process, check out this blog post.

Keep in mind, though, that this advice isn’t purely for direct access patients. Just because you receive a diagnosis code from a referring provider doesn’t mean you can accept that code blindly, plug it into your documentation and your claim forms, and expect to get paid. You should use the physician diagnosis to inform you on the patient’s situation, but then use your own clinical judgment and skills as a medical professional to diagnose the patient based on what you’re actually going to treat. To learn more about selecting diagnosis codes that help justify treatment, check out this blog post.

What’s the difference between medical diagnosis and treatment diagnosis?

The treatment diagnosis is the one that represents the injury or condition that you, as the therapist, are treating. The medical diagnosis is typically the one that comes with a referral patient’s script. Usually, the treatment and medical diagnoses match. If they don’t, it’s a good idea to get the physician to sign off on the treatment diagnosis before you bill.

Are there V codes in ICD-10?

ICD-9’s V codes will become Z codes in ICD-10, but as explained in this blog post, “A simple mapping of the V57 series of codes found in ICD-9-CM over to ICD-10-CM is not possible, as codes that duplicate the V57 series currently are not included in ICD-10-CM classification.” Furthermore, because V57.1 does not provide specific, detailed information about the patient’s diagnosis—and thus, does not justify the medical necessity of the treatment—using a similar code in ICD-10 could lead to claim denials. Instead, you should select whatever code explains the patient’s diagnosis in the most specific way possible. For more on the importance of coding for medical necessity, check out this blog post.

How do I code for surgical aftercare?

As explained in this resource, the aftercare Z codes should not be used for aftercare of injuries/fractures where seventh characters are provided to identify subsequent care. That said, you won’t always be providing aftercare for injuries—especially in cases involving surgical aftercare. For that reason, ICD-10 contains a few options for coding for surgical aftercare. A couple examples: Z51.89, Encounter for other specified aftercare, and Z47.1, Aftercare following joint replacement surgery. Please note that when you use aftercare codes, you also should code for any underlying conditions/effects. Codes for bone, muscle, and joint conditions that are chronic or recurrent—or that result from a healed injury—are typically found in chapter 13. Also, if you’re coding for joint replacement aftercare, you should include a code indicating which joint was replaced (e.g., V43.65, Joint replaced, knee).

What if I don’t have enough information to select a more specific code?

Select the most specific code you can based on the information you have. In some cases, you may need to contact a referring provider for additional information. But if you’ve exhausted all options and still can’t obtain the information necessary to select a more specific code, just make sure you clearly document the reasons behind your code selection within your documentation.

What if a more specific ICD-10 code does not exist?

ICD-10 requires you to code as specifically as possible, but there may be instances in which codes for your specific diagnosis do not exist, and you’ll have to use an unspecified or generalized code. You can’t code for what you don’t know; just make sure you communicate all the details in your documentation. To learn more about when to use unspecified codes, check out this blog post.

Do I remove codes as my patient improves?

If the patient’s primary diagnosis changes, and you need to update the plan of care, then you should update the diagnosis code. However, if the patient is simply making progress, you can document his or her progress as normal.

How many ICD-10 codes do I have to add for each patient?

There is no minimum or maximum number of codes you can record (though not all will necessarily flow through to your billing, and obviously, you will need to enter at least one). Just make sure you order the diagnosis codes you do submit in order of importance, with the primary diagnosis at the top.

Can’t I just use the ICD-10 code I receive from the referring physician?

Because clinical judgment is such a crucial part of selecting the appropriate diagnosis code, the therapist may need to get involved with code selection to ensure that:

  1. The selected code is the most specific one available to describe the patient’s condition, and
  2. The code justifies the medical necessity of the services provided.

In some cases, the codes sent by referring physicians may meet that criteria, but ultimately, it’s your clinic’s responsibility to code correctly. After all, it’s your clinic—not the physician’s—that will end up suffering the consequences for inaccurate coding. Don’t just take the physician’s word as gospel. Your physicians don’t have the depth of neuromuscular knowledge and expertise that you do. You are best equipped to make the most specific diagnosis possible, and that is exactly what ICD-10 requires.

How do I code for multiple body parts?

For single conditions involving multiple sites, such as osteoarthritis, there often is a “multiple sites” code available. If no “multiple sites” code is available, you should report multiple codes to indicate all of the different sites involved. For a patient seeking treatment for multiple conditions involving multiple body parts, you would create separate cases just as you do with ICD-9.

If a patient is experiencing the same condition on both sides (i.e., right and left), how do I code for that? I noticed some ICD-10 codes don’t have “bilateral” options.

In some categories and families of codes, there is no “bilateral” option for denoting laterality. In those cases, you would need to submit separate codes for both the left and the right sides. This is for data-tracking purposes (e.g., tracking the total number of “left” and total number of “right”).

If a patient has multiple diagnosis codes, which one should be the primary diagnosis?

Your primary diagnosis code should be the one that most closely aligns with the reason the patient is seeking your services. From there, you should order the codes according to importance and significance regarding medical necessity.

Whew! That was a lot of information, right? Hopefully, it helped ease your mind. But remember these are the answers to only your most burning questions. Need more ICD-10 advice? We’ve got your back. Check out these posts—and tons more—on the WebPT Blog:


Physical Therapy ICD-10 Coding Example

August 28th, 2015
Codes, ICD-10, ICD-10 Example, Preparation

Don’t you just love word problems? We do—so we created a fun ICD-10 word problem just for physical therapists. Don’t worry; we’ve provided the answer, too. Ready to learn how to code for ICD-10? Then, here we go!

The Example

ACL sprain

The Patient

The patient is a 16-year-old male. During his high school soccer game last week, the patient sprained his ACL when his knee came into contact with another player’s leg. He comes to your office without a physician referral and is using crutches for ambulation. He also presents with:

  • Pain, especially while walking
  • Edema
  • Instability in his right knee

The Codes

Primary Codes

  • S83.511A for sprain of anterior cruciate ligament of right knee, initial encounter.
    • Because this is a direct access patient, you’d use “A” as the seventh character.
  • W51.XXXA for accidental striking against or bumped into by another person, initial encounter.
    • This external cause code further describes the factors leading up to the injury.
  • Y92.322 for soccer field as the place of occurrence of the external cause.
  • Y93.66 for activity, soccer.

Additional Codes

These codes indicate the reasons for outpatient therapy:

  • R26.2, Difficulty in walking, not elsewhere classified, or R26.89, Other abnormalities of gait and mobility
  • M25.561, Pain in right knee
  • M25.361, Other instability, right knee
  • M25.461, Effusion, right knee

The Description Synonyms

Did you notice you could code either R26.2 (difficulty walking), or R26.89 (other abnormalities of gait and mobility)? You’ll need to use your patient evaluation and best clinical judgement to determine which code better describes the reason for the patient’s disordered movement. Each code has its own synonyms that can help you make your selection:

Difficulty walking

The description synonyms for R26.2 are:

  1. Difficulty walking
  2. Walking disability

Other abnormalities of gait and mobility

The description synonyms for R26.89 are:

  1. Cautious gait
  2. Gait disorder due to weakness
  3. Gait disorder, painful gait
  4. Gait disorder, weakness
  5. Gait disorder, postural instability
  6. Gait disorder, multifactorial
  7. Toe walking and toe-walking gait
  8. Limping/limping child

The Summary

This example has codes for days, so if you’re still a bit confused—or having panicky flashbacks to that dreaded linear algebra class—we get it. That’s why we’re hosting our ICD-10 Bootcamp on August 31. During this free, 90-minute online webinar, we’ll provide a step-by-step explanation on how to locate ICD-10 codes in the tabular list, in the index, and in WebPT. Make sure you register here to reserve your spot.


Dual Coding: When One isn’t the Loneliest Number

June 1st, 2015
Codes, ICD-10

October 1 is fast approaching, and that means it’s nearly time for ICD-10 implementation. Hopefully your staff is trained and prepared to use the new codes in all of their updated and more descriptive glory. While you might be clear on the deadline and what you need to do to prepare for it, the idea of dual code submission might not be as crystalline. Here’s the lowdown:

The Dates

First, you can’t submit both ICD-9 and ICD-10 codes on the same claim. Not happening. So, which code set should you use? That depends on the claim’s date of service—not the date of submission. That means any claims submitted for dates of service before October 1 should contain ICD-9 codes. And the ones with dates of service on or after October 1? You guessed it: Those claims should contain ICD-10 codes. This is something you will need to monitor closely in your clinic. In the event that you do end up submitting a claim containing both ICD-9 and ICD-10 codes, you must split the claim. (Just be sure to ask your payers about their splitting specifications first.) So, even though ditching ICD-9 altogether—at least at first—isn’t feasible, it doesn’t mean you need to be stuck in dual coding limbo.

The Do

You probably don’t want this dual coding period to continue on for too long—and luckily for you, there are some steps you can take to shorten the process. Start by examining how quickly you’re preparing claims; then, adjust your processes to accommodate those timelines. Or, set goals to get the claims out even more quickly. Ideally, you should submit all claims within 24 hours of the date of service. This will help speed up the process of denial management. Another way to shorten your dual coding time is to figure out how long a typical claim is open. Once you have a rough idea of how long it takes for both ICD-9 and ICD-10 codes to process (again, not on the same claim), you’ll be able to account for any additional processing time.

The Deal

If you already have solutions in place to help you transition to ICD-10, that’s great. If not, you should start looking for some software solutions—sooner, rather than later. If you do already have systems in place, then—in addition to examining your own processes—you’ll want to ask your EMR system, third-party vendors, billing services, and clearinghouses if they can handle both ICD-9 and ICD-10 codes. Ideally, all of your vendors will have already taken this transitional period into consideration.

The nitty-gritty details of the transition to ICD-10—including dual coding—might seem a bit muddy. However, with some preparation, it doesn’t have to be a big mess. Are you ready to handle coding for both ICD-9 and ICD-10? Share your thoughts in the comments section below.


What You Absolutely, Positively Must Know About External Cause Codes

April 23rd, 2014
Codes, ICD-10

The ICD-10 code set might possibly be some of the most boring reading material on the planet—unless, of course, you’re into that sort of thing. But I think it’s safe to say that the mainstream media probably isn’t, which is most likely why they’ve spent so much of their time highlighting the more entertaining aspects of the coding manual: specifically, the external cause codes in Chapter 20. Sure, these supplemental codes offer a healthy dose of comic relief to an otherwise dull subject matter, but they’ve spurred quite a few questions and some concerns. So here are the five things you absolutely, positively must know about external cause codes:

1. Most of the time, they’re optional. Per the ICD-10-CM Official Guidelines for Coding and Reporting, “Unless a provider is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer, reporting of ICD-10-CM codes in Chapter 20, External Causes of Morbidity, is not required.” However, even though there’s no national requirement forcing the issue, there are a plenty of good reasons to include external cause codes when you can. After all, they do “provide valuable data for injury research and evaluation of injury prevention strategies.” And according to this article, such data could instigate important preventative education and action. Take motorcycle accidents, for example: If data showed a high frequency of motorcycle accidents in a particular area, local leaders could use that information to demonstrate the need to devote budget dollars to additional motorcycle safety education.

2. You can’t use them all the time—even if you want to. In some cases, adding an external cause code to a diagnosis code simply doesn’t make sense, like in the case of T36OX1 (poisoning by penicillins, accidental), which has the cause built right in. And external cause codes can’t stand alone; they must always be paired with a principal diagnosis code.

Not sure to which codes you can apply an external cause code? Check the tabular list. Above each applicable diagnosis code category, you’ll see instructions to do so.

3. There are four types of external cause codes, each of which answers one of the following questions:

  • How did the injury or condition happen?
  • Where did it happen?
  • What was the patient doing when it happened?
  • What it intentional or unintentional?

You can apply as many external cause codes as necessary to fully explain the patient’s condition. Here’s an example: Let’s say this is the first time you’re treating a patient for a strain of his right Achilles tendon. You’d select the diagnosis code S86.011A (strain of right Achilles tendon, initial encounter). After examining the patient, you find that the patient’s injury occurred as a result of running on the treadmill at a gym he visits for recreation (not work). To code for this, you’d submit the following external cause codes:

  • Y93.A1 (activity, treadmill)
  • Y92.39 (gymnasium as the place of occurrence of the external cause)
  • Y99.8 (other external cause status, recreation or sport not for income or while a student)

4. If you choose to use them, you only need to do so at the initial encounter (for the most part). Typically, you need only to report place of occurrence, activity, and external cause status codes during the patient’s initial evaluation. However, there are a few codes—specifically those that describe how an injury happened—that you can report at other points throughout the patient’s care. These codes usually require a seventh character designating the encounter type.

5. If you’re using multiple external cause codes for a single diagnosis code, report them in order of significance. The first cause code you list should be the one that most closely relates to the principal diagnosis; the last code you list should be the one that least closely relates. However, according to the official coding guidelines, external cause codes for the following events take precedence over all other external cause codes, in the following order of significance (abuse should be listed first no matter what else you code):

  1. Child and adult abuse
  2. Terrorism events
  3. Cataclysmic events
  4. Transport accidents

See, despite all the fuss over external cause codes—and the jokes about patients being struck by an orca—they’re really not that bad. Want a more in-depth look at external cause coding? Check out section 20 of the official coding guidelines. As always, if you have questions, leave them in the comments section