ICD-10 and Direct Access

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


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


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 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 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.


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.