With ICD 10 coding guidelines take into consideration how ICD 10 codes are processed
In 1860, when Florence Nightingale first proposed a model of hospital data to keep statistics on the causes of death, little did she know it would eventually lead to ICD 10 coding guidelines and the ICD 10 coding system.
Likewise, most doctors are unaware of the impact choosing the most specific diagnosis has on its use in reimbursement and showing the medical necessity of treatment. It is hard to believe that ICD-10-CM, with nearly 73,000 codes, has now been used for over seven years in the United States. The ICD statistical classification system is the most widely used in the world. However, only in the U.S. do we use the coding system for reimbursement. The codes you use will directly affect your reimbursement. Therefore, specificity is the word that most commonly relates to proper diagnosis code selection today.
Your documentation and coding must tell a story. Knowledge of proper coding techniques will help convey the whole story in case management, communication in the report of findings and proving medical necessity.
ICD 10 coding guidelines
The World Health Organization (WHO) has established guidelines for coding conditions. An essential rule in the coding guidelines is that the provider must code what they know and be as specific as possible when choosing codes.
The codes you put on the claim form and the order in which they are placed are your first line of communication with an insurance carrier. Utilization guidelines in the software systems of many insurance carriers take the diagnosis codes and convert those into the probable number of treatments. Therefore, the code you use on the claim form must be substantiated, documented and reported “to the highest degree of specificity.”
Your documentation of the history, subjective complaints and objective findings will indicate the proper diagnosis code to use. The more specific your documentation, the easier it will be to defend your treatment plan. Even a “cash practice” is scrutinized by other entities such as risk managers, malpractice attorneys and the board of examiners.
Codes such as cervicalgia (M54.2) and lumbago (M54.5) are commonly used by chiropractors. These codes are considered non-specific codes. They merely state that the patient has neck pain or back pain but do not tell us why. Ask yourself, why does the patient have neck or back pain? This will typically give you a more specific diagnosis.
Pinpointing the cause
There are ICD-10 codes that indicate if the condition is on the right side or the left, a chronic or acute condition, and the patient’s phase of care. Injury codes have a seventh character called the extension.
The extension provides information about the characteristics of the encounter. The extension will indicate if the patient is in the active phase of care, the rehabilitation or healing phase, or is suffering from a sequela of the injury.
Code order and placement
When reporting multiple diagnoses, keep in mind that you are communicating to a computer.
In addition to using the codes to their highest specificity, the order or hierarchy of the codes will also affect the adjudication of the claim. Medicare, Medicaid and the Veterans Health Administration (VA) require the segmental and somatic dysfunction (subluxation) codes (M99.1 – M99.05). When required, this code is always placed in the first position on the claim form. However, other commercial insurance and liability carriers may not require the segmental and somatic codes in regard to ICD 10 coding guidelines. Since the computer reads the first code as the primary condition you are treating, it may be advantageous to list the segmental and somatic code second.
I am not belittling the effects of the subluxation but rather optimizing code placement to tell the whole story to the computer software.
Certain conditions are affected or “complicated” by other disorders in the body. When present, neurologic conditions such as sciatica would be listed first if present. You would next list structural problems such as degenerative disc disease, then functional disorders such as atrophy, soft tissue problems next, and complicating factors are listed last. If one of the categories of a condition does not exist, then do not list it. However, the order of the conditions, when present, is of utmost importance.
Complicating factors such as hyperpronation of the feet or plantar fasciitis will slow the recovery time of an ailment. If a condition affects the recovery or stability of a disease, it should always be listed in the last position in a diagnosis list.
Confirmation of conditions
If a disorder is suspected or probable, it cannot be placed on the claim form until verified. You may wish to enter it in your documentation, but it cannot be placed on the claim form until objective confirmation of the condition exists.
Tools such as radiology reports, foot scanners and laboratory reports will aid in accurate proof of a condition. By utilizing tools available to you, you can document the true nature of the disorder. Scanning every patient’s feet will uncover complicating factors you may be missing. Likewise, radiology reports may shed additional information. Even if you do not own an X-ray machine, when medically necessary, ordering the X-rays to be done at an imaging center or obtaining past radiologic reports should be considered. If a patient had degenerative disc disease three years ago, they still have it.
Factor in all conditions
Conditions such as bunions, short-leg syndrome or hyperpronation of the feet often will disrupt the gait and functional kinetic chain of the patient. These factors may come into play when considering treatment options. Strive to be concise in the reporting of all conditions that are causing the patient’s instability and treat if possible.
Knowledge is power, and the power of the proper ICD-10 code selection will assist in appropriate documentation of the medical necessity of your treatment following ICD coding guidelines. Utilizing tools at your disposal will aid in deriving a specific diagnosis along with all complicating factors that contribute to the patient’s clinic picture. Once the picture becomes clear, then you can truly tell the whole story.
MARIO FUCINARI, DC, CPCO, CPPM, CIC, is a member of the Medicare Carrier Advisory Committee and also on the speaker’s bureau for Foot Levelers, NCMIC and ChiroHealthUSA. Contact him for classes such as Medicare, documentation, coding, examination or rehabilitation training at Doc@Askmario.com or visit his website at Askmario.com.