ICD-10 This week
Written by Editor   
Wednesday, November 18, 2015 12:53 PM

So Far, So Good

The new ICD-10 coding system has been in place for nearly 4 weeks, and so far implementation appears to be proceeding relatively smoothly. Some worried that physician practices wouldn't be ready to implement the new system when it debuted on Oct. 1, but that doesn't seem to be an issue thus far.

Medicare Part B contractors have been listing a few issues on their websites. Despite these issues, overall it has been positive.  The ongoing concern now, experts said, is what will happen on the "back end" when the insurers process more of the claims they've received. We are still in limbo in terms of ... how claims will be adjudicated.  Humana and UnitedHealth Group both said that things were going smoothly for them, but also that they taken a fairly liberal approach to coding – but they also said that was not going to last forever.  The biggest challenge is going to be seeing how many payers are actually going to leverage their ability to deny services because providers haven't documented the diagnosis code descriptors in their commentary of electronic health record notes, which is required to meet medical necessity. If the diagnosis cannot be deciphered from the notes to match what diagnosis code was billed, then the payer can deny the claim or recoup monies.

Providers need to be trained for this type of documentation, which isn't going to add much more time to their workload other than a minute or less in their documentation.  However, "most providers did not go through this education, and documentation has always been the biggest challenge for providers. 

When it comes to Medicare claims, providers need to make sure they really understand the position of the Centers for Medicare and Medicaid Services. Although the general perception was that Medicare was going to be lenient with claims processing as long as the diagnosis code was in the correct coding family -- even if it wasn't exactly the right code -- CMS put two clarifications in that policy. They say the local coverage edits and national coverage edits continue to apply to claim submissions, but the flexibility is on the auditing side.  For 12 months, the auditor will not be rejecting a code due to the lack of specificity of the code. That's a very different interpretation to what a lot of folks had.

ICD-10 common questions

Q: Do we need to populate each of the 12 spaces available for diagnosis?

A: No. There is not a distinct number of diagnosis required for claim submission. However, you must use adequate and appropriate diagnosis to fully support each of the services rendered.

Q: Do we need to add x's to ICD-10 codes to make each code 7 characters in length?

A: No. ICD-10 codes can be up to 7 characters in length. Most codes do not require 7 characters.  You will not add additional x's to any codes.

Q: Our claims are being rejected. What is the reason for this?

A: First, check each of your diagnosis used to ensure that you have not inappropriately added any digits or characters to a code that is not required by ICD-10 guideline and coding instructions.

Secondly, check to make sure that your software isn't including the diagnosis decimal point onto the claim forms as this is not required on claims and will result in rejection.

Third, for those codes that do require the 7th character (such as the 'S' codes), make sure this character is being properly added.

Finally, if all of the items above are in proper order, it would be best to check directly with the payer to determine if there is perhaps a processing glitch being addressed or if there is policy available that identifies codes that may not be acceptable on claims for that payer.

Q: How do you code for a bilateral condition, such as sciatica?

A: There are not many codes for use in chiropractic that define a bilateral condition. In the instance where there is a bilateral condition, you would need to use two codes, one for the right side and the other for the left side. Using the sciatica example, the codes would be: M54.31 and M54.32.

Q: We cannot find codes to identify the left or right side of the spine, such as with low back pain. Do we add digits 1 or 2 to the code to clarify left or right?

A: No. Codes pertaining to the spine are not specific to laterality. The codes that do require laterality specificity are for the extremities. Do not add any characters or numbers to any codes that do not specifically require this in the coding instructions. This will result in erroneous coding and a rejection or denial. 

Q: How do we know which codes a payer will allow?

A: Many of the ICD-10 codes translate very closely or even identically in some cases from ICD-9 to ICD-10. It is likely that these direct or very similar crossovers in ICD-10 will process in the same manner as they had previously with ICD-9. That said, there are of course many new codes, combination codes and much more specific codes than what was available in ICD-9. Providers should continue to use those diagnosis that are within their scope to diagnose and that most closely support patient documentation.

More specific information as to which codes are best to use in certain circumstances will likely be defined by individual payers in the weeks and months to come. CMS, the ACA and other governing entities will also help to clarify certain ICD-10 issues that arise. As always, billing personnel must carefully watch claims, review EOBs and be proactive in following up with any uncertainties to best familiarize with payer expectations for ICD-10 billing.

Q: We have visit dates that occurred before 10/1/15. Should these be billed in ICD-10?

A: No. ICD-10 is the required code set for dates-of-service as of 10/1/15 and after. Dates-of-service prior to the ICD-10 effect date must have the appropriate ICD-9 diagnosis on those claims.

Q: Do we need to update box 14 (Date of Current) for all visits on and after 10/1/15?

A: No. The ICD-10 implementation date of 10/1/15 required only that diagnosis codes be updated to the appropriate ICD-10 code set for all visits on and after that date. Box 14 should be updated as it is appropriate per the particular patient case. The translation from ICD-9 to ICD-10 does not warrant an updated box 14.

How do I code for ...

Muscle Spasm or Contracture of the muscles

To code for a contracture for the muscles of the extremities, see codes M62.411-M62.49.

Various sources define “contracture of the muscles” as abnormal shortening of the muscle tissue, rendering the muscle highly resistant to stretching.  It can be caused by fibrosis of the tissues or by disorders of the muscle fibers themselves. 

Some sources refer to it as a “permanent” condition. Contractures are essentially muscles or tendons that have remained too tight for too long, thus becoming shorter. Once they occur, it is often argued that they cannot be stretched or exercised away. Most of the manual therapy regimens focus on trying to prevent contractures from happening in the first place. However, research on sustained traction of connective tissue in approaches such as adaptive yoga has demonstrated that contracture can be reduceat the same time that tendency toward spasticity is addressed.

To code for a "muscle spasm" of extremities, see code M62.838.

Various sources define “muscle spasm” as an involuntary contraction of one or more muscles.

Disc Herniation

There are two categories to choose from for spinal disc disorders:



Each one has the same fourth character options:

0= disc disorder with myelopathy
1= disc disorder with radiculopathy
2= other disc displacement
3= other disc degeneration
4= Schmorl’s nodes (not available for the cervical region)
8= other disc disorders
9= unspecified disc disorder


The fifth character provides detail about the anatomical location within that spinal region.

Here are a couple of tips to keep in mind when using these codes:

  • It may be helpful to consider that “disc disorders” include protrusions, bulges, and herniation, and this is the term used for the fourth characters “0” or “1”. “Disc displacement” for the fourth character “2” also could include those things, but it does not include cord or nerve root complications.
  • Don’t code radiculitis (M54.1-) separately if you use the fourth character of “1”, “with radiculopathy”, for the disc disorders (M50.1- or M51.1-). It is already included in the code.

 Likewise don’t code sciatica (M54.3-) if you code for lumbar disc with radiculopathy. It would be redundant. On a side note, lumbar radiculopathy (M54.16) might be used if the pain is not known yet to be due a disc but it does radiates from the lumbar spine. The same condition, without confirmation of a disc, might be coded as sciatica (M54.3-) instead if it radiates all the way to the back of the leg.

  • Don’t code cervicalgia (M54.2) along with the cervical disc disorders (M50-), and don’t code low back pain (M54.5) along with lumbar disc displacement (M51.2-). Those symptoms are included with the more definitive disc diagnoses.
  • Currently there is a strange rule for cervical disc disorders that says you should code to the most superior level of the disorder. It seems to imply that you would only code M50.11 if the problem occurs all throughout the neck.
  • Only use the fourth character “8” for “other disc disorders” if none of the other fourth character choices fit. Consider all the others first. 
  • Only use the fourth character “9” for “unspecified disc disorders” if the documentation does not state anything more than there is a disc problem. But beware, payers are expected to ask for clarification if “unspecified” or “NOS” codes are used.
  • The fifth character options include transitionary regions. “Cervicothoracic” is clearly designated as C7-T1. Though it is not specifically mentioned, “thoracolumbar” likely only includes T12-L1, and “lumbosacral” probably only refers to the L5-S1 interspace.

Sources: http://www.medpagetoday.com/PracticeManagement/Reimbursement/54344