The switch to ICD-10 is coming on October 1, 2015, and to transition successfully, healthcare providers will need to change not only the actual codes they are using, but also the way they think about coding. Because with ICD-10, it’s not just about coding patient diagnoses correctly; it’s about coding the correct patient diagnoses.
This point is especially relevant to physical therapy providers. As this article explains, “Medical necessity can be a big problem in the physical therapy department.” Why? Well, in many cases, the condition a physical therapist treats is not technically the same condition that the referring physician treated. Sure, the patient may be seeking therapy for a condition that resulted from the original injury or condition—a common scenario for therapy referrals—but with ICD-10, it is absolutely crucial that the diagnosis coding accurately reflects that distinction.
To cut to the chase, that means a physical therapist cannot simply copy whatever ICD-10 code a physician sends over with a referral patient, because there’s a good chance that diagnosis code doesn’t validate the medical necessity of therapy treatment—and that means payers could deny reimbursement for the therapist’s services. The above-cited article offers the following example: “A patient suffers a stroke and is attending physical therapy. A lot of patients suffer strokes and don’t need physical therapy. The therapy is actually treating the residual effects of the stroke, so that’s what should be reported as the diagnosis on the claim form.”
Furthermore, the article addresses the now-common practice of using diagnosis code “cheat sheets” to ensure payment. As you probably know, certain CPT codes are only payable when used in conjunction with certain ICD-9 codes. For that reason, many providers stick to the codes they know will work—and often, those codes fall into the “generalized” or “unspecified” categories. But 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.
And in the event that you do receive a denial, make sure you investigate the reason. The article I referenced earlier urges providers to research the following question: “Are the denials due to a lack of medical necessity or a lack of documentation?” The author also recommends that each practice designate one person to be responsible for following up on such denials.
Does your practice have a game plan for any claim denials you receive due to ICD-10? What advice or questions do you have?