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?


Direct Access and ICD-10: What You Need to Know

September 23rd, 2015
ICD-10, ICD-10 Example, Patient care, Preparation

The transition to ICD-10 is causing many providers to change how they run their practices. But if you have a cash-pay clinic or find yourself working mostly with direct access patients, you may be wondering how the heck ICD-10 will affect you.

Here’s the deal: while you may not deal with payers often, you’ll still need to take them into consideration, especially if your clinic submits bills to your patients’ insurances on their behalf. And even if you don’t, there’s a good chance your patients submit bills to their insurances directly, so you should still have a firm grasp on how to code in ICD-10. Here are some tips:

1. Ask specific questions.

Because you don’t have a referral diagnosis, coming up with the medical—and treatment—diagnosis is totally on you (even if you had one, you’d still want to be sure the referral diagnosis was as specific as possible). To begin, throw on your best reporter hat and ask yourself these questions:

Who

Who is this patient? Is he or she new to your practice?

What

For what reason am I seeing this patient? What happened to this patient to cause his or her present condition?

Where

If you are treating a patient who has suffered an injury, consider where the injury occurred. (In addition to adding an external cause code to designate the place of occurrence, be sure to select a diagnosis code that accounts for the anatomic site of the injury in the most specific way possible.)

When

When did the injury occur? Is the patient in the active phase of treatment, or is he or she healing or recovering from the injury or condition (i.e., can you apply a seventh character, and if so, have you selected the appropriate option)?

Why

Why is the patient seeking rehab therapy? Think in terms of causation: rather than simply coding for knee pain, for example, try to account for what actually caused the knee pain (i.e., the underlying condition).

The answers to these questions will help you navigate the code index or tabular list, but coding correctly will take a bit more effort.

2. Learn the alphabet.

Forget the ABCs; you’re going to want to know the ADSs. These three letters are ICD-10’s seventh characters, which are exactly what they sound like: the seventh character of a code. They hold a special place in the new code set—and they could make or break your claims. So, make sure you know how and when to use them:

A – Initial encounter

The patient is receiving active treatment for his or her injury or condition.

D – Subsequent encounter

The active phase of treatment for the patient’s injury or condition has ended, and the patient is now in the healing or recovery phase of treatment.

S – Sequela

This one’s reserved for complications or conditions directly resulting from an injury. A commonly used example of a sequela is a scar that results from a burn.

Keep in mind that not all codes have seventh characters. This character position is only 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). If you’re still confused about how and when to use the seventh character—and trust me, you’re not alone—check out this blog post.

3. Use your noodle.

To code successfully using ICD-10, you must code for medical necessity—and that all comes down to clinical judgement. ICD-10 demands that providers select the codes that best fit the patient’s condition—not just the codes that will get paid—so your knowledge and experience will play a crucial role in coding. An EMR can assist you in this process, but it can’t replace you (after all, you are the musculoskeletal expert—not your technology).

And don’t forget about your documentation. Defensible documentation may be a jargony term, but it also is a key piece of the ICD-10 pie—even if your patients come to you directly. There’s no excuse for not creating thorough and specific documentation that supports your diagnosis and plan of care. By the same token, if you determine the patient’s condition is outside your scope of practice, then refer out.

4. Hit the books.

Not sure you have the right resources to help you make the transition successfully? Consider obtaining a quality, PT-specific coding book that offers guidance around coding strategy and processes. Not only would it be useful for educational purposes, but it also would help you put together a list of your clinic’s most-frequently-used ICD-10 codes. But with so many coding books out there, which one should you purchase? We suggest Instacode: ICD-10 Coding for Physical Therapy. And if you’re a WebPT Member, you’re in luck. You can purchase the book through the WebPT Marketplace at a discounted rate.

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Even if you haven’t previously considered how ICD-10 will affect your direct access or cash pay clinic, we’re here to make sure the transition to the new code set doesn’t induce hives or hyperventilation. Eager to learn more about these tips—or WebPT’s ICD-10 tool? Join us for our free, one-hour ICD-10 Crash Course webinar from 9:00 AM to 10:00 AM Pacific time on September 24, 2015.

 


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.


Will ICD-10 Eradicate Paper Superbills?

September 21st, 2015
ICD-10, ICD-9, Transition

To a regular person, the idea of doing away with something called a superbill might sound alluring. I, for one, would love to trash the supersized energy bill I received after running my air conditioner throughout the month of August in Phoenix. For healthcare providers, however, the term “superbill” has a whole different meaning: it’s “a form used by medical practitioners and clinicians so they can quickly complete and submit the procedure(s) and diagnosis(s) for a patient visit for reimbursement,” explains the American Academy of Professional Coders (AAPC).

Many ICD-10 prep resources—including ICD10forPT—have encouraged providers to create ICD-10 versions of their current ICD-9 superbills, an exercise that:

  1. Helps practitioners get comfortable with navigating the ICD-10 code set, and
  2. Produces a helpful ICD-10 resource specific to each individual practice.

But while converting your ICD-9 superbill to ICD-10 is a great way to learn the ICD-10 ropes, it definitely shouldn’t be your only training activity. Furthermore, keep in mind that paper superbills won’t carry nearly as much weight in the post-ICD-9 world. In fact, relying on a superbill to guide your practice’s coding decisions likely will be a losing strategy with ICD-10. Here’s why:

1. Many ICD-9 superbills contain general codes.

In the interest of saving space, most superbills feature a hefty portion of “unspecified” or “not otherwise specified” ICD-9 codes. And while those codes might be enough to generate payment now, they’re just not going to cut it after the big switch. After all, one of the driving forces behind the move to ICD-10 is the global call for greater detail when coding patient diagnoses. For that reason, “ICD-10 requires you to code to the highest possible level of specificity,” explains this blog post. But mapping one general code to another defeats the purpose of the transition—and, more importantly, puts your practice at risk for denied payments.

2. Crosswalking tools often map ICD-9 codes to non-specific ICD-10 equivalents.

For the superbill conversion strategy to work well in practice, you’d need to find a single ICD-10 code to sub in for each ICD-9 code. And I hate to be the bearer of bad news, but you don’t have a snowball’s chance in the Sonoran Desert of doing that—at least not in a way that would meet the aforementioned specificity standard. In fact, in many cases, the quest to find a one-to-one match for a fairly specific ICD-9 code will actually lead to a less-specific ICD-10 code. The AAPC offers the following example to illustrate this point: CMS’s crosswalk maps the ICD-9 code 845.00, Sprained/strained ankle, unspecified, to both S93.409A, Sprain of unspecified ligament of unspecified ankle, initial encounter, and S93.409D, Sprain of unspecified ligament of unspecified ankle, subsequent encounter. “However, this is incomplete because it does not include a code for a strained ankle,” the article points out.  

3. More coding specificity means more codes.

Superbills are meant to be quick resources, and the ones currently in use probably don’t have enough room to accommodate all relevant ICD-10 codes. That’s because, as this ICD10forPT article states, “…for each ICD-9 code, there could be dozens—sometimes even hundreds—of possible ICD-10 equivalents.” And there’s no way to know which one to use until you have a real, live patient in front of you, because you’ll need to have a complete picture of the patient’s situation in order to select the code that most accurately represents his or her specific diagnosis. So, while your incumbent superbill might fit nicely on one page, your ICD-10 version could explode to nearly ten pages—or even more. As Gayl Kirkpatrick, a solution sales executive for 3M HIS Consulting Services, tells Government Health IT in this article, “We took a two-page superbill in ICD-9 and translated that into ICD-10…It became a 48-page superbill.”

4. Paper is so last-millenium.

The transition to ICD-10 represents a huge step forward for the entire US healthcare industry. This is the code set of the future (of the present, actually—after all, we’re the last major country in the world to take the ICD-10 plunge). It’s not just about us; it’s about collecting and analyzing data to raise the bar for patient care on a global scale. And to do that, we have to move away from the paper systems of old and embrace the technology that will usher us into a new age of health care. Who needs a printed list of codes when they have innovative, intuitive coding tools at their fingertips—tools that allow them to approach coding in a wholly patient-centric way? When you think about it that way, paper just can’t compete.

 

While paper superbills probably won’t disappear as fast as popsicles at an Arizona summer picnic, they will become less useful—and less reliable—come October 1. Looking for a better way to streamline diagnosis code selection? Click here to see a solution that puts paper superbills to shame.    


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:


ICD-10 Talk with Dr. Heidi Jannenga: Why ICD-10?

September 14th, 2015
ICD-10, ICD-9

Our previous ICD-10 Talk video covered the basics of ICD-10 and explained the features that distinguish it from its predecessor, ICD-9. In this second video of our ICD-10 Talk Series, Dr. Heidi Jannenga tells us why the US needs to make the transition to ICD-10. Additionally, she provides clarification around a common point of confusion: is it date of service or date of claim submission that dictates whether a provider should use ICD-9 codes or ICD-10? Check out the video now to find out, and stay tuned to ICD-10forPT.com for more great videos and other educational materials as we get closer to transition time.


ICD-10 Coding Practice for OTs: Down Syndrome

August 31st, 2015
ICD-10, ICD-10 Example, Preparation, Transition

Are you an ICD-10 coding expert? Do you feel prepared to take on the complexities that are an inevitable—yet, crucial—component of the new code set? No? Well, not to worry. ICD-10 is certainly complex, and you should take this transition seriously. Still, you shouldn’t let fear (and frustration) get the best of you. With that in mind, what can you do to make the transition smoother? Practice, practice, and well, more practice. Speaking of practice, here’s an occupational therapy coding example from compliance expert Rick Gawenda. Walking through this example should help you fine-tune your coding skills. Here’s the situation:

The Patient

The patient is a 7-year-old female with Down syndrome (meiotic). Her parents have been referred to occupational therapy, because she’s having problems with her posture and walking. She appears to be suffering from muscle weakness. How would you code for this?

The Codes

Primary Code

  • Q90.0, Down syndrome. More specifically, this code indicates the patient’s diagnosis of Trisomy 21, nonmosaicism (meiotic nondisjunction).

Additional Codes

With ICD-10, you should indicate the reason for outpatient therapy whenever possible. In this case, you would use the following codes:

  • R26.2 for the difficulty walking or R26.89 for other abnormalities of gait and mobility
  • M62.81 for generalized muscle weakness
  • R29.3 for abnormal posture

The Description Synonyms

You’ll have to use your clinical judgement to determine whether you’d code R26.2 (difficulty walking) or R26.89 (other abnormalities of gait and mobility). During your evaluation, you likely will find that one code is more appropriate than the other. One way to determine which code you should select: review each code’s description synonyms. Here are the description synonyms in this situation:

Difficulty walking. The description synonyms for R26.2 are:

  • Difficulty walking
  • Walking disability

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

The Summary

When all’s said and done, coding to the highest level of specificity requires you to change your mindset. When you account for additional information pertaining to each patient’s condition, you’re able to determine which codes accurately explain the scenario. Feeling better about the transition after reviewing this example? Want to see more examples like this one? Watch WebPT’s free ICD-10 bootcamp webinar. In it, we provide step-by-step guidance on how to code for this example—and ones that are even more complex. With our help, you’ll be ready well before October 1.


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.


ICD-10 from the Patient’s Perspective

August 19th, 2015
ICD-10, Patient care, Transition

We know you’re working hard to get your clinic ready for ICD-10. From the front office to the back, every person in your practice is gearing up for October 1, 2015—except for your patients. But that’s not a bad thing. In fact, in most cases, your patients don’t even need to know about ICD-10. Have you ever explained ICD-9 codes to a patient? Probably not—and your patients have likely never asked about them, either. So why would that change along with the healthcare industry’s code set?

Hint: It wouldn’t.

Patients won’t suddenly develop the urge to learn about medical billing just because you’re switching to ICD-10. The majority of your patients are much more concerned with getting better than they are about the codes you’re using to bill their insurances. Besides, informing patients of ICD-10’s demand for greater documentation specificity might cause them to unnecessarily question your pre-ICD-10 documentation practices.

Ultimately, when it comes to switching code sets, what your patients don’t know won’t hurt them—unless you expect your clinic’s productivity to take a deep dive, especially with respect to the speed of patient intake. Even in that situation, you don’t need to spend 30 minutes explaining (or complaining about) the transition to ICD-10. Instead, simply tell patients that, due to new government regulations, your staff must complete additional paperwork, which has caused some temporary front office delays. Any patient who’s had to file taxes will cut you some slack.

Luckily, you’ve got one less thing to worry about when it comes to preparing your practice for ICD-10. To put all of your coding concerns to rest, don’t miss our upcoming ICD-10 Bootcamp webinar on August 31, 2015. Register here to save your spot.  


ICD-10 Talk with Dr. Heidi Jannenga: What is ICD-10?

August 19th, 2015
ICD-10, ICD-9, Preparation, Transition

As you’re probably—hopefully—well aware, the transition to ICD-10 is happening in about six weeks. And this is no tiny tweak; on October 1, 2015, all HIPAA-covered healthcare providers in the entire US must begin coding patient diagnoses using codes from the new ICD-10 code set. To help rehab therapists take on this change confidently—and emerge from ICD-Day unscathed—we’ve provided tons of free ICD-10 educational materials, from blog posts and guides to interactive games and webinars. And now, we’re upping the ante with video: introducing ICD-10 Talk with Dr. Heidi Jannenga.

In the first video of this new series, Heidi provides a brief explanation of ICD-10 and how it differs from ICD-9. Stay tuned for more awesome ICD-10 Talk videos, and be sure to check out the rest of the resources available here on ICD10forPT.com. Have a question? Submit it using the question form at the bottom of this page, and we’ll round up an answer for you.