Coding the Kinetic Chain Disruption
POSTURE
BIOMECHANICS
Mario P. Fucinari
DC, CP CO, CP PM, CIC
Dr. Mario Fucinari is a certified professional compliance officer, certified physician practice manager, certified insurance consultant, and a Medicare Carrier Advisory Committee member. As a member of the Foot Levelers Speaker ,’s Bureau, Dr. Fucinari travels throughout the year, speaking to audiences across the country, sharing his chiropractic expertise and insights about using custom three-arch orthotics for optimal care.For further information, email him at Doc a Askmario. com or visit his website at www.Askmario.com.
As chiropractors, we understand that a segment’s mobility dysfunction will affect proximal and distal segments to the first segment.
Chiropractors treat a variety of conditions, but the majority of the complaints we treat are musculoskeletal disorders. People who seek chiropractic care do so 64% to 86% of the time for spine-related needs (Coulter et al., 2002). Kinetic chain disruptions are a common theme when considering the causation of what we treat. However, conveying disruptions of the kinetic chain poses a challenging problem when assigning diagnosis codes to our patients.
The kinetic chain concept was first introduced by Franz Reuleaux in 1875. Reuleaux proposed that rigid, overlapping segments were connected via joints, creating a system whereby movement at one joint produced or affected movement at another (Andrew, 2002). As chiropractors, we understand that a segment’s mobility dysfunction will affect proximal and distal segments to the first segment.
I will admit that I am a people watcher. I am intrigued by watching the gait of people in public and analyzing where the dysfunction is located, which affects the gait pattern. Admit it, don’t you do the same? Chiropractors are hard-wired to observe dysfunction.
When we communicate the causation of a condition to a third party, we often must assign an alphanumeric code that best describes our assessment. Currently, over 74,000 diagnosis codes are available to us. We are tasked to be as specific in our diagnosis as possible. Code what you know but be as detailed as possible when using codes. Signs and symptom codes are only to be assigned if those codes represent the highest level of specificity known by the provider. Therefore, using unspecified codes, such as cervicalgia, low back pain, and muscle spasms, is discouraged. They do not tell the entire story.
The “kinetic chain” of our thought process starts at the consultation. The consultation tells us what the problem might be, and the examination determines the condition. The analysis used in medical decision making tells us what the situation truly is, while the diagnosis tells others what the disorder is. Diagnosis codes justify our treatment based on the infonnation found in the patient record and on the claim fonn. The kinetic chain of thought is known as medical necessity. If one segment of the thought process is misaligned, the medical need for care is not supported. The documentation and coding of medically necessary care must therefore be specific.
Injuries can be acute, such as a lifting injury, or cumulative, such as upper or lower cross syndromes. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) lists trauma and injury codes in chapters S and T. The S and T codes are six-character codes with an A, D, or S appended at the end. The appended codes will signal to a third party whether the patient’s condition is in the active acute stage (A), the healing or recovery stage (D), or a sequela due to another existing condition (S). Communication of the disease, the stage of the condition’s recovery, and the complicating factors involved are essential for proper justification of the medical necessity of our care.
The Impact of Complicating Factors
Just as impatient teens ask if we are there yet, insurance companies and peer reviewers wonder why the patient is not well yet. Patients do not all heal at the same rate. Some have conditions, such as degenerative arthritis, muscle weakness, or hyperpronation syndrome of the feet, that impede the healing process. These impediments are known as complicating factors. Complicating factors affect patient recovery. According to the World Health Organization’s coding rules, complicating factors that affect patient care should always be listed last in the diagnosis list (ICD-10-CM, 2023). When showing the medical necessity of care, complicating factors will increase the time needed to resolve a condition.
To demonstrate the mles, let’s take a patient seen in the office primarily with neck and low back pain and secondarily with mid-back pain, headaches, and foot pain bilaterally when arising in the morning. An examination, including a kinetic chain visualization using digital foot scanning, reveals that the patient has multiple subluxations, asymmetric anterior and posterior muscle tone in the cervical, thoracic, and lumbar regions, muscle weakness in multiple muscle groups, and hyperpronation syndrome causing foot pain and dismption of the kinetic chain.
Since the spinal problems indicate upper and lower cross syndrome, we diagnose the patient with a cervical sprain, lumbar sprain, thoracic sprain, cervical strain, lumbar strain, thoracic strain, and plantar fasciitis complicated by muscle weakness/deconditioning of multiple muscle groups. The example of the specific ICD10 code set would result in the following codes in this order:
• S13.4xxA Cervical sprain
• S 3 3.5 xxA Lumbar sprain
• S23.3xxA Thoracic sprain
• S16.1 xxA Cervical strain
• S39.012A Lumbar strain
• S29.012A Thoracic strain
• M99.01 Segmental and somatic dysfunction cervical
• M99.03 Segmental and somatic dysfunction lumbar
• M99.02 Segmental and somatic dysfunction thoracic
• M72.2 Plantar fasciitis/Plantar fascial fibromatosis
• M62.59 Deconditioning of muscles, multiple sites
The coding is complex because it is a complicated case. The medical necessity of manipulation, therapeutic exercises, and custom flexible three-arch orthotics to stabilize the entire body is demonstrated and justified by the chosen diagnosis codes. The documentation in the patient record must also explain the code selection. Therefore, the specific coding of the kinetic chain disruption is accomplished.
Awareness of the diagnosis rules and code selection by the provider will effectively communicate to a third party the total picture of the condition, the complex nature of the disorder, and the medical necessity for a multilevel approach to treatment.
References
1. Coulter, I. D., Hurwitz, E. L., Adams, A. H., Genovese, B. J., Hays, R., & Shekelle, R G. (2002). Patients using chiropractors in North America: Who are they, and why are they in chiropractic care?. Spine, 27(3), 291-298. https://doi. org/10.1097/00007632-200202010-00018
2. Andrew T. L. (2002). Closed kinetic chain exercise. A comprehensive guide to multiple-joint exercises. Journal of Chiropractic Medicine, 1(4), 200. https://doi. org/10.1016/S0899-3467(07)60039-l
3. ICD-10-CM Official Guidelines for Coding and Reporting FY 2023 — UPDATED April l,2023,pg. 16. https://www.cms.gov/ files/document/fy-2023 -icd10-cm-coding -guidelines-updated-01/11/2023 .pdf.
