DC, CPC, NCICS, CCPC, CCCPC, CPC-I, MCS-P, CPMA T he ICD-9 codes that have been used on claim forms since the late 1970s will cease to exist as of October 1. 2014. Chiropractic physicians don"t have the same resources at their disposal as mam large clinics and physician groups. The majority of doctors of chiropractic are small business owners. They frequently do not employ an army of certified coders to help them handle their transition to ICD-10-CM coding. According to the 2010 Practice Analysis of Chiropractic by the National Board of Chiropractic Examiners (NBCE). 55.4% of chiropractic practitioners employ one or more chiropractic assistants (CAs). Only 28.8% of those CAs arc employed full time. With just a few employees, who has the time to train the staff and keep up with all the coding changes that arc coming? As a result, issues such as a new diagnosis code set tend to be low on the priority list, and mam- providers bun their heads in the sand. They'd rather learn a new technique to help treat their patients, or invest in new equipment. The truth is that there are major changes coming in how claims are submitted and adjudicated. Providers must devote time and energy to understanding ICD-10 codes in order to stay in business. History The World Health Organization (WHO) directs and coordinates health functions around the world. They have created a list of codes called the International Classification of Diseases (ICD) that is used worldwide for morbidity and mortality statistics. In order for these codes to be useful for reimbursement and claims submission, the National Center for Health Statistics created a clinical modification for use in the United States, which is why the current data set is called ICD-9-CM. The first revision came out in 1900. and a new an update was released even ten years or so until the ninth revision came out in 1979. In 1993. the WHO released a new update called ICD-10-CM. which was made ready to use in a clinical setting in 1997. Sixteen years later, the rest of the civilized world has been using ICD-10-CM for a long while. The US will be the last developed country to adopt ICD-10-CM. mostly because of those complaining about the cost and time involved in making the change. Procrastination Is Not an Option Some providers may have been relieved when they heard that the implementation date was moved from October 1. 2013 to October 1. 2014. Some coders and healthcare providers hope that the next date will be postponed as well. In fact, there are mam optimistic procrastinators. Last year the American Medical Association (AMA) petitioned the Centers for Medicare & Mcdicaid Services (CMS) to postpone or even skip ICD-10 implementation (and go straight to ICD-11). The coding world got ncn ous until Marilyn Tavcnncr. acting administrator for CMS. spoke up and reaffirmed that the conversion will not be postponed. On February 6. 2013. Tavermcr wrote. "Halting this progress midstream would be costly, burdensome, and would eliminate the impending benefits of these investments. Mam private and public sector health plans, hospitals and hospital systems, and large physician practices arc far along in their ICD-10 implementation and have devoted significant funds, resources and staff to the effort." She further stated. "We believe the one-year extension to September 30. 2014. offers physicians adequate time to train their coders, complete system changcovcrs. and conduct testing. Staying the course with ICD-9 is not sustainable in an electronic health environment." Therefore, it can be concluded that the date is definitely final and absolute...maybe. The truth is that preparation must be based on the know ledge currently available. No one knows what the government might do next. Regardless, it is wise to begin ICD-10 education now. It can't be learned the night before the implementation date. In other words, don't procrastinate. What's Wrong with the Current System? Anything that has been around since the 1970s can now be classified as "old." ICD-9 was released in 1979 and it just can't keep up with changes in health care. There are new tcchnolo- gies and science lias a better understanding of the nature of many diseases. The code set is finite—limited to the numbers 001 to 999 (plus E and V codes). Some sections have run out of room for expansion, but perhaps most importantly. ICD-9 codes lack detail. Providers often select "unspecified" codes because they are the only option. In terms of health care, that is not ideal. Detail is better. ICD-10 improves the capture of information. It is so detailed that payers should no longer need to request a copy of the medical records to adjudicate claims. According to the American Academy of Professional Coders, this better data is expected to lead to improved patient safety, improved quality of care, and improved public health and bioterrorism monitoring. ICD-10 provides more specific information, contains five times as mam codes, and lias much clearer clinical descriptions. For example. ICD-9 docs not include codes to differentiate between sides of the body. Since the "70s. scientists learned something very important: there arc two of many body parts. ICD-10 includes details such as one code for the right eye. and a different code for the left eye. Most would agree that this is a necessary improvement. See the table below for other changes. Key Differences Between ICD-9 and ICD-10 Number of Codes About 14.000 About 68.000 Number of Characters • 3-5 characters in length Sonic arc numeric Some start with "E" or "V" • Decimal is used after 3 characters • 3-7 characters in length Character 1 is alpha Character 2 is numeric Characters 3-7 arc either Decimal is used after 3 characters Some codes use "x" for characters 4-6 Characters 7 used in certain chapters Number of Chapters 17 plus E and V chapters 21 chapters Start Date 1975, 1979 in US 1994. 2014 in US Expansion Very Limited Has significant ability to expand without a structural change Detail Lacks Detail Very specific Laterality Lacks Laterality Includes laterality when appropriate Encounters Initial and subsequent encounters arc not defined Initial and subsequent encounters arc defined Combination Codes Combination codes are limited Combination codes are frequent How Docs This Affect DCs? It is hard to say which ICD-10 codes that third-party payers will select as medically necessary. Some say that even the payers wont know until the last possible minute. However, an educated guess can be deduced based upon information from a few sources. For doctors of chiropractic (DCs), the natural place to start is with the relatively short list of ICD-9 codes that are frequently used when submitting claims. A handful of diagnosis codes that Medicare recognizes as medically necessary have been selected and then investigated here in attempt to explore the ICD-10 code possibilities. The Subluxation Medicare administrative contractors (MACs) release local coverage dctcnninations (LCDs) for chiropractic. Most require that the first diagnosis code be selected from the 739 category (non-allopathic lesions, not elsewhere classified). The ICD-9 definition of this code docs not really describe what it is. but rather what it isn't. This has long been a source of frustration to chiropractic coders, since the documented phrase used by chiropractic physicians is usually the so-called "vertebral subluxation." The fine print in ICD-9 docs further explain that this could be "segmcntal or somatic dysfunction." but from a purely semantic point of view, it does not hold the same meaning. Throughout ICD-9. the term "subluxation" is used to describe a "partial dislocation." which is not how many chiropractors define it. This is more in line w ith injuries tliat are immobilized and medicated by an allopathic medical provider. Medicare defines the subluxation reasonably well on behalf of the chiropractic profession: "A motion segment, in which alignment, movement integrity and or physiological function of the spine are altered although contact between joint surfaces remains intact. For the purposes ofMedicare, subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebra anatomically. " Simply, it is a condition of minor, sometimes painful misalignment that is treatable by manipulation. ICD-9 has never provided a code that differentiates between the chiropractic subluxation and the allopathic subluxation. Chiropractors have been compelled to try to fit a square peg into a round hole for many years. With its expanded detail, it appears that ICD-10 is a chiropractic coder's dream. At first glance. ICD-10 offers a wide range of new possibilities: however, the debate is still undecided. If the General Equivalence Mappings (GEMs) arc used as a starting point for this investigation, the commonly used ICD-9 code of 739.1 (non-allopathic lesions: cervical region. cervicothoracic region) may be replaced with M99.01. which is "scgmcntal and somatic dysfunction of cervical region." This differs little from ICD-9 and still docs not use the word "sub-luxation." However, nearby the code M99.ll is found, which is defined as "subhixation complex (vertebral) of the cervical region." This sounds just like the verbiage most chiropractors use. but the GEMs point this code back to 839.00. not 739.1. in ICD-9. 839.00 (closed dislocation, cervical vertebra, unspecified) is not allowed by Medicare. In Chapter 19 (Injuries) of ICD-10. there are several appealing codes in the S13.11 category. They arc defined as "subluxation of cervical vertebrae." The new codes provide information about the specific spinal level, whether it is a subluxation or dislocation, and whether the encounter is the initial or follow-up visit. This uses the word "subluxation" and includes detail that chiropractic physicians have never been able to report using ICD-9. Unfortunately. GEMs point these codes back to the 839 category again rather than the 739 category in ICD-9-CM. This implies that these new codes may be intended for use by allopathic physicians for dislocations, rather than for the chiropractic subluxation. No one has come forward to let chiropractic coders know if they should use M99.01. M99.11, S13.11. or something else. Other Ncuromusculoskclctal Diagnoses According to the local coverage determination from Arizona, which has Noridian as its Medicare administrative contractor (MAC), the secondary diagnosis selected by the chiropractic physician must come from a list of about sixty choices. These ICD-9 codes are separated into three categories. Category I generally requires short-term treatment (around 6-12 visits): category II generally requires moderate-term treatment (around 12-18 visits): and category III may require long-term treatment (18-24 visits). One cervical diagnosis has been selected from each category and investigated below. Chiropractic is primarily concerned with disorders of the musculoskclctal and nervous systems, so the old and new codes will come from those respective chapters in ICD-9 and ICD-10. Short term There are 16 ICD-9 codes listed in this category I. or conditions that require a short term of care. One of the most commonly used is 723.1 (ccn icalgia). It simply means "neck pain" and is not a very specific code. This is probably why it is considered "short term" in the LCD. General Equivalence Mappings (GEMs). which only give approximations, suggest M54.2. This new code has the same definition, so it seems like a straightforward one-to-one map. There are a few details to consider, however. In ICD-9 this code excludes conditions due to intervertcbral disc disorders. Those arc coded using the 722 scries, which happen to be category III codes. In other words, if this qualifies, the category Ill codes should be used instead, since Medicare recognizes that this type of neck pain may require longer-term treatment. There is another lesson here as well. M54.2 in the ICD-10-CM code set has an "excludes 1" note regarding ccrvicalgia due to intcn crtcbral disc disorders (in M50). "Excludes 1" is a new convention in ICD-10 that tells us that these two codes may not be used together, ever. If it were an "cxcludcs2." that would mean that the two conditions can coexist, but both must be coded to adequately report the situation. Moderate Term Category codes may require a moderate term of treatment. A commonly used code from this list of 36 codes is 847.0 (neck sprain). The GEMs point to two codes in this instance: S13.4xxA (sprain of ligaments of the cervical spine) and S13.8xxA (sprain of joints and ligaments of other parts of the neck). The difference is that the first code lists three specific ligaments as well as whiplash injury. The other code covers anything else in the neck. ICD-10 provides payers with a little more detail since there is now more than one code to describe this condition. Medicare may likely replace the ICD-9 code with both of these ICD-10 codes. However, they may only choose to cover the first code. That is just part of the mystery. There are a couple of ICD-10 coding convention lessons here as well. These new codes contain seven characters, but the fifth and sixth arc just "x" because they arc placeholders. The>- don"t add meaning to the code: they simply make sure the seventh character stays in the seventh position where it is supposed to be. The seventh character here could be either "A" (initial encounter). "D" (subsequent encounter), or "S" (sequela). So there arc actually six possible codes. The ability to report on the status of the encounter is new in ICD-10. and may be found with several codes that chiropractic physicians will use. It appears tliat the code will end with the letter "A" on the first visit and "D" for follow-up. The "S" would only be used if the condition has technically resolved, but the patient is still experiencing problems a long time later. Medicare may not approve of cquel codes since they may fit better with their definition of "maintenance care." Long Term There arc only a dozen codes to choose from in the section listed as category III. and they arc the most serious. Patients with these conditions may require long-term treatment, according to the LCD. A commonly used ICD-9 code from this section is 722.4 (degeneration of a cervical intcn crtcbral disc). This includes the "ccrvicothoracic" region as well. The GEMs lead us to M50.30 (othercervical disc degenera- tioa unspecified cervical region). This is another great example of how GEMs just get the coder pointed in the right direction, but docs not take him or her all the way to the end of the journey. M5O.3O is an "unspecified" code. One of the reasons that ICD-10-CM exists is to keep providers from using "unspecified" codes. A deeper investigation reveals that M5O.31 specifics the occipito-atlanto-axial region. M50.32 specifics the mid-cervical region, and M50.33 specifies the cervicothoracic region. It would be great if GEMs simply provided the code that will be approved when ICD-10 is finally implemented, but. in this example, the result is an unspecified code. It is likely that Medicare will not cover M5O.3O. but the other three specified codes (M5O.31. M50.32. and M5O.33) will appear on the new LCD. Thus, providers will have to indicate that level of detail in their documentation, which was not necessary previously. What's Next'.' As the implementation date approaches, more information may come forward and better guesses can be made. It is rumored that Medicare will release ICD-10 based LCDs in October 2013. In the meantime, this type of investigation will allow coders and physicians to find new issues and possibilities. However, the question remains: Which codes will payers require for chiropractic physicians? The payers must rewrite their guidelines around the new codes. Selection of the correct codes depends upon the whim of the payer, not the GEMs. Since 95% of the ICD-10 codes do not map one-to-one, the new list will look very different. For now. coders and providers must simply do their best to get familiar with the new system and make calculated guesses. Providers who want to be ready to transition to ICD-10 need to train themselves and their staffs. Seminars, webinars. and books arc becoming more available as the date approaches. Several agencies offer credentials for trainers who can provide consulting help. At a minimum, ten minutes of ICD-10 training at each staff meeting can create a solid foundation for a well-prepared clinic. Regardless, procrastination is not the answer. References AAPC.com/ICD10 Centers for Medicare and Mcdicaid Services & Noridian Administrative Services. February 27. 2012. Local Coverage Determination (LCD) for CHIROPRACTIC Services (L24288) Chirocodc. 2011. Complete & Easy ICD-10 Coding For Chiropractic, First Edition Medicare Learning Network. October 2011. Chiropractic Sen ices (ICN 906143) htip://\v\vvv.cms.gov/eHeallli/LislServ_ICD10_AHeaIlhCarcPriorilv. html NBCE.org Dr. (hvilliam is a licensed Chiropraclic Physician who is also a cerli/ied coder, compliance specialist, and medical auditor. He serves on the Editorial Board for K1) I O.\ lonilor.com and leaches CE programs around the V. S. for C 'ross C "ountry Education and the ChiroCode Institute, lie has published coding and compliance articles in several publications and recently added "American Academy of Professional Coders Certified ICD-10 Trainer" to his long list of certifications. I
