ICD-10: The Devil is in the Details

Editor’s Note: The Illinois Chiropractic Society will be hosting a webinar covering The Specifics of ICD-10 on December 10, 2013. Members have access to all of our online education here.

It is hard to believe that the deadline for mandatory implementation for ICD-10 is less than one year away. On October 1, 2014, the United States will implement the World Health Organization’s (WHO) mandate for the clinical modification of diseases and morbidity classification. This is known as ICD-10-CM. The National Center for Health Statistics (NCHS) is the Federal agency responsible for use of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) in the United States. Despite the wrangling of the U.S. government on Obama Care, ICD-10 has nothing to do with Obama Care and will not be delayed nor go away.

Transition to ICD-10

Utilization Guidelines take the diagnosis codes and convert those into the probable number of treatments. In preparation for the ICD-10 transition on October 1, 2014, I will attempt to prepare you and your staff for the transition over the course of several articles. Due to the conversion, physicians will need to modify the way they collect patient data and document visits in their charts. “Specificity” is the word most often associated with ICD-10 documentation, and physicians will be required to collect more information in more detail in order to select the right ICD-10 code for a symptom or condition. Therefore, the code you use on the claim form must be substantiated, documented and reported “to the highest degree of specificity.”

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The WHO does not care about your reimbursement. It is their job to keep track of the causes of diseases, injuries, and mortality. Since certain diseases and injuries are endemic to a region, the WHO has authorized each country to clarify which codes they will use in their own specific region, and CMS has been given that authority by WHO for the United States. Meanwhile, the maintenance of statistics, such as how many new cases of polio were diagnosed in the world in 2012, will remain with WHO. Incidentally, there were 223 new cases reported in 2012 worldwide.

Specifics

In the ICD-10 classification system, the documentation will yield the code used. The more specific your documentation, the easier it will be to find the code. Certain codes such as Cervicalgia (M54.2 in ICD-10) will convert easily from ICD-9 to ICD-10. Other codes such as Sciatica, will now have choices including the left side, right side, or not side specific, and accompanied by back pain or not accompanied by back pain. In other words, your documentation will determine which code to pick out of the six possible choices for sciatica in ICD-10.

In ICD-10, the number of characters used in the codes will grow from the possibility of three to five characters in length (ICD-9), up to three to seven characters in length. There will be codes for the right side and the left, chronic versus acute, and initial encounter, subsequent encounter, and sequelae. In fact, because of the specificity, we have now expanded the codes from a set of about 17,000 codes to over 70,000 codes. Of course, most chiropractors routinely use between 35-60 codes now and will ultimately expand their use to about 200 codes under the new system.

Utilization Guidelines

Insurance companies are looking for guidance from the Centers for Medicare and Medicaid Services (CMS) for further clarification on which specific codes are to be acceptable in the chiropractic profession. CMS is expected to clarify the specific code set to use on or about April 1, 2014. It stands to reason that since Utilization Guidelines are established for the ICD-9 codes, they will eventually be established for the ICD-10 codes as well. We can assume that the more specific codes will be desired and generalized, non-specific codes may be deemed “not medically necessary.”

As an example, if you were determining if a claim was payable, would you pay for a claim where the physician diagnosed the patient with shoulder stiffness, but they did not know which shoulder? I hardly think so. It is therefore reasonable that the unspecified code (M25.619) is the code that is not desirable because it is least specific.

Example of code specificity. You would want to use the right or left-sided code, rather than the unspecified code.

Within the 70,000+ codes, there are 25,230 codes that will be impacted if they are unspecified, right or left codes.

In addition to side specificity, some of the codes also require a seventh character at the end to denote if the encounter is the initial encounter, subsequent encounter or for treatment for a sequela. Many of the codes we as chiropractors use will be impacted by the “ordinality” of the code (According to The American Heritage Dictionary, ordinality is “indicating the position in a series or order”). To date, there are 47, 223 codes that are impacted by the ordinality. Thankfully, we will not regularly use all of them. In the encounter, a code such as S93.401 Sprain of the Ankle will require the seventh character to let us know the ordinality. Therefore, you may use S93.401A on the initial encounter, then S93.401D for the very next encounter. Hopefully, your computer software will prompt you or automatically check for the correct code.

7th Character Basic ICD-10 Coding Guidelines:

A – Initial encounter

D – Subsequent encounter

S – Sequela 

Practices should be preparing for the upcoming ICD-10 change requirement on October 1, 2014. Physicians and staff need to closely examine how they are documenting the cases and implementing policies and procedures to make the transition seamless. Look for further articles coming over the course of the next several months. Classes will also be offered by the Illinois Chiropractic Society to help prepare you and your staff. Look at our website at www.ILchiro.org

Upcoming Courses

Dr. Fucinari and the ICS will be presenting several classes in the coming months to aid the doctor and staff in correct compliance procedures. For an updated schedule of classes and locations, go to www.illinoiscme.com, www.ilchiro.org/ or www.AskMario.com. Dr. Fucinari is a Certified Medical Compliance Specialist and a Certified Insurance Consultant. Dr. Fucinari is the author of several books, including, ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office, available at www.Askmario.com For further information on compliance audits, books or record reviews, please contact Dr. Fucinari at Doc@Askmario.com