ACA Coding & Insurance Tips, Dec. 2015
Written by Editor   
Sunday, December 20, 2015 10:43 PM

Coding specifics and payer updates from the ACA will help you to stay current with billing procedures.

Q. How do I code laterality with sciatica if the patient experiences symptoms in both legs?

A.  The ICD-10 Code set offers the following codes for sciatica:

  • M54.30 Sciatica unspecified;
  • M54.31 Sciatica, right side;
  • M54.32 Sciatica left side.

Since there is not a code for bilateral sciatica you would report both M54.31 and M54.32. It is important to note, if you need to report low back pain (lumbago) with sciatica, you would want to code from one of the following combination codes rather than listing the conditions separately:

  • M54.40 Lumbago with sciatica, unspecified side;
  • M54.41 Lumbago with sciatica, right side;
  • M54.42 Lumbago with sciatica, left side. 

Q. How do I code lumbago with disc displacement?

A. Before a provider would report low back pain using code M54.5 it would be necessary to consider all the Instructional Notes found under the M54.5 category.

One of the conditions listed under the Excludes 1 note is lumbago due to intervertebral disc displacement. If the patient were experiencing this condition, the provider would choose a code from the suggested category M51.2, Other thoracic, thoracolumbar and lumbosacral intervertebral disc displacement.  The provider would then choose the most specific code that describes the patient's condition from the following:

  • M51.24 Other intervertebral disc displacement, thoracic region;
  • M51.25 Other intervertebral disc displacement, thoracolumbar region;
  • M51.26 Other intervertebral disc displacement, lumbar region;
  • M51.27 Other intervertebral disc displacement, lumbosacral region.


Q. What are some of the things I should include in my documentation because of ICD-10?

A. In general, in addition to standard documentation, you may need to include details such as laterality, anatomical site (level of subluxation or dysfunction), and etiology.

For example, with an injury diagnosis your documentation should report type, location (such as muscle or ligament to separate strain from sprain), stage of care and external cause. For a condition such as headache you must document type, persistence, and cause.



Aetna - ACA has been notified of denials from Aetna when providers report sprain diagnoses such as S13.8xx_, S16.1xx_, S23.3xx_, and S33.5xx_. 

These conditions in some cases are being denied as non covered or investigational. We encourage providers to follow Aetna's appeal process and refer to the language from Aetna's  chiropractic policy that considers sprain and strains as covered neuromusculoskeletal conditions.

Additional resources are available on Aetna's provider education website at or on Aetna's Health care Professionals Dispute process, which can be found in the FAQs section. If appealing on behalf of the patient, please note Aetna's requirement to fill out an Authorized Representative Request Form.

Anthem's EDI ICD-10 Edits - a list of ICD-10 related edits by transaction can be found here.

UHC -  Claim Reconsideration to be Retired!  Early in 2016, UHC is going to switch to Link because of its enhanced capabilities. If you need access to the applications on Link, your Password Owner can update your account in User ID and Password Management. You can view your Password Owner's name by logging in and going to "My Profile." For help using the apps on Link, please refer to UHC's Quick Reference Guides. They also offer one-hour webinars on the second Thursday of each month. Be sure to sign up in order to be able to access the claims resolution process for issues that may surface during initial stages of ICD-10 changeover.

Centers for Medicare and Medicaid Services (CMS) - ACA has contacted Noridian with regard to the wrongful denials involving diagnosis codes M99.01-M99.05.  At this time, the issue has not been fully resolved. We will update members once we know more.  Additional information is available here.  If you need assistance with ICD-10 claims, CMS has provided the following resources:

According to HIMSS (Healthcare Information and Management Systems Society), “CMS has created some short-term remedies to the national coverage determination errors such as: refining coding and updating claims processing instructions.  More long term updates will be in place by January 4, 2016.  Meanwhile, CMS said that some errors resulting from local coverage determinations occurred because some Medicare Administrative Contractors (MAC) needed to update certain criteria. The agency said it delayed processing those claims until the contractors' updates were in place." 

Stay in the Know! The HIMISS ICD-10 Taskforce interviewed several payers and clearinghouses about their initial experience with ICD-10.  One important question from the interview was: "Do you have a designated line for providers to call with questions?"

This question was answered by the following vendors:


HIMISS plans to interview providers on their experience with implementation of ICD-10 and will post this information in late December.

Many providers are coding their claims properly but not submitting them correctly. Do not let all your hard work go to waste! Be sure to schedule time with your billing staff or service to review the reason codes for any claim rejections. By staying proactive you can avoid any additional financial loss.

Some areas that deserve close consideration:

  • Submit the correct ICD qualifier on the claim. Be sure that the qualifier is listed as '0' when submitting claims with ICD-10 diagnoses. Additional information is available in ACA's 1500 Health Insurance Claim Form Fact Sheet.

  • Submit one type of ICD diagnosis on a claim. Do not submit dates of service prior to October 1st with ICD-9 codes on the same claim as dates of service with ICD-10 codes.

  • Check your diagnosis pointers. Be sure that Item Number 24E is pointing to the diagnosis that supports the condition treated by the procedure listed in the line item.  For example, procedure code 98941 should point to three or four diagnoses that support CMT such as M99.01, M99.02 and M99.03.



SOURCE:  American Chiropractic Association