If this headline got your attention, it’s time to talk diagnosis coding.
You frequently see articles titled something about how coding errors plague the profession, and if this one did you might have moved right along and missed the message.
Paramount to this is what is heard over and over again from DCs: I want to make money and avoid an audit.
But first, a question for you: Are you diagnosing the patient’s condition or just what you know their insurance will reimburse? In other words, are you diagnosing based on the patient’s history, examination, and radiology findings, or are you simply using an ICD-10 cheat sheet of the most common codes that get paid?
In 2013, there were high hopes ICD-10 would help get the profession on the right track with the correct
methodology in diagnosing coding. Unfortunately, what we have seen is a continuance of outdated and, quite honestly, incorrect coding policies that have been handed down from one generation to another in chiropractic.
Well, I heard . . .
When teaching ICD-10 coding classes, there are always multiple questions that start with “Well, I heard…” What usually follows is a recitation of something that someone told an insurance CA to do, coding that is incorrect.
The CA follows the recommendation from the well-meaning doctor or coworker, and the insurance reimbursements arrive. But never believe just because you are receiving payments that your office is doing things the right way with coding.
Sequencing is everything
The number one error in chiropractic coding you see is in the sequencing of the diagnosis codes on the claim form. I have seen some highly unusual listings of codes and, when asking who taught this, was informed, “Well, I heard…” The hierarchy of the codes starts with the chief complaint and then any additional complaints of the patient. For example:
A patient presents with a chief complaint of lower back pain, with a secondary complaint of neck pain. You must list all diagnoses that correlate to the lumbar spine before moving onto the neck. But instead the complaints are often mashed together to look like this on the claim:
Incorrect sequencing
- M99.03 Segmental and somatic dysfunction of the lumbar spine
- 01 Segmental and somatic dysfunction of the cervical spine
- 5 Low back pain
- 2 Cervicalgia
Correct sequencing
In this example of a chief complaint of lower back pain, with a secondary complaint of neck pain, this would be the correct sequencing.
- 03 Segmental and somatic dysfunction of the lumbar spine
- 5 Low back pain
- 01 Segmental and somatic dysfunction of the cervical spine
- 2 Cervicalgia
Hierarchy to code by
It is now time to take this coding stuff to another level and bring in the correct hierarchy to code by on your claims. Starting with your chief complaint and then moving on to each additional complaint, follow this hierarchy and
you will be coding correctly.
- Neurological
- Primary structural
- Disc pathologies
- Facet syndrome
- Arthritis
- Scoliosis
- Spondylolisthesis
Secondary structural (these are your segmental and somatic dysfunction codes, or your traumatic subluxation codes)
- Soft-tissue
- Pain
- Comorbidities
- External cause codes
Coding pearls to live by
A neurological condition exists when you have a positive neurological finding during motor, sensory, or deep-tendon reflex testing.
Primary structural is the anatomical structure(s) causing the neurological condition. In the absence of a neurological condition, move onto the primary structural diagnosis. Degeneration, arthritis, and spondylolisthesis must have validation by radiology, MRI, or CT findings. Be careful with pain diagnoses so that they do not interfere with disc codes.
Start using comorbidity codes such as hypertension, diabetes, multiple sclerosis, etc. With any comorbidity that the patient states they have been diagnosed with, if you feel it could hamper their recovery, code it last.
For personal injury, workers’ compensation and returning Medicare patients, please use the appropriate external cause codes.
Are you crazy?
Whenever I teach this hierarchy of coding, there is always someone in the room who thinks I am crazy because this is so foreign to them. No, I am not crazy, and I have coded this way since becoming a certified professional coder in 2007. We do not have denials or decreased insurance reimbursements with this coding sequencing.
What about Medicare?
You use the same hierarchy, which will look like this if done appropriately.
- Segmental dysfunction (M99.01, M99.02, or M99.03)
- Neurological
- Segmental dysfunction (M99.01, M99.02, or M99.03)
- Primary structural
- Segmental dysfunction (M99.01, M99.02, or M99.03)
- Soft-tissue
- Segmental dysfunction (M99.01, M99.02, or M99.03)
- Pain
Why it matters
Doing this correctly can help you earn more money and avoid an audit. Diagnosing is an art, philosophy, and science. DCs must get back to using their clinical skills and judgment when diagnosing patients. Your history, examination, and radiology findings drive your diagnoses, not the codes the insurance company will reimburse.
Ted A. Arkfeld, DC, MS, CPC is the director of risk management for Best Practices Academy. Arkfeld is one of the nation’s leading authorities in chiropractic coding and documentation. He has authored two textbooks and is a much-sought-out speaker for state conventions. He can be contacted through bestpracticesacademy.com.
