PROPER USE OF ICD-9 CODES FOR THE CHIROPRACTIC PROFESSION
 
   

Proper Use of ICD-9 Codes for
the Chiropractic Profession

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

By Alan Lyons, D.C.

A free online ICD-9 tool is available to help you create
the most specific coding possible at
FlashCode.

INTRODUCTION


The importance of proper coding of a diagnosis cannot be overstressed. Accuracy is essential to reimbursement for services rendered and to protection from both malpractice and civil litigation.

In the past several years, I have personally collected dozens of diagnosis code lists -- from doctors, software manufacturers, practice management/advisory groups and billing seminars. Not one of these lists was written with the exceptions/exclusions and specific requirements necessary to proper coding. Without knowing the exceptions and exclusions pertaining to a particular code it is almost certain that an incorrect code will be used on a large percentage of patients.

Let's look at some examples:

353.0   brachial plexus compression

353.2   cervical root lesions

723.1   cervicalgia

723.2   cervicocranial syndrome

723.3   cervicobrachial syndrome

723.8   cervical syndrome

724.02   lumbar spinal stenosis

724.5   backache (pain) syndrome

All of these codes are commonly used in many chiropractic offices. However, all of these codes, as well as many others, are specifically excluded in any condition, which is in any way disc related, or involves spondylosis (osteoarthritis). These 8 codes do not support chiropractic manipulation because they do not describe a misalignment. It is easy to understand how a chiropractor, without this knowledge of exceptions, may erroneously code an incorrect diagnosis.

Repeatedly making incorrect diagnoses can lead to problems with your State Board. Remember, the doctor has the ultimate responsibility. Using a list full of mistakes and/or omissions is no excuse. An incorrect diagnosis, followed by repeated treatments, may also lead to indefensible malpractice charges.

With the Americans With Disabilities Act more disabled persons are filing A.D.A. claims. The Ninth Circuit Court of Appeals has affirmed that a disabled person can be stopped from pursuing an A.D.A. claim because of the way an ATTORNEY OR DOCTOR documents the disability (e.g. inappropriate ICD-9 code), or because of the manner in which the person with the disability or the Doctor testifies at deposition, or both, as a matter of law. (Kennedy v. Applause, Inc.) In short, when you assign an inappropriate code, you may be sued, and forced to pay for that person's disability!

Many of the codes may be interpreted as applying to more than one area, with a slightly different description relating that code to that anatomical area -- such as 728.85, muscle spasm, thoracic myospasm, etc. In some cases there exists a considerable discretion as to the description, in others there is none. Only with a codebook can you be sure.


GUIDELINES FOR USING ICD-9-CM CODES

A)   Diagnosis Codes Must Support the Procedure Codes

Each service/procedure billed for a patient should be supported by a diagnosis that would substantiate those particular services or procedures, as necessary in the investigation or treatment of their condition, based on currently accepted standards of practice by the chiropractic profession.

Some of the "basic" HCFA guidelines are summarized below. The focus is on guidelines that would affect the chiropractor.

1.   Indicate on the claim form or itemized statement the appropriate code(s) from the ICD-9-CM code range 001.0 through V82.9 to identify diagnoses, symptoms, conditions, complaints or other reason(s) for the procedure, service or supply provided.

a.   Codes in the range 001.0 through 999.9 are for the classification of diseases and injuries. Codes that describe symptoms are only acceptable if that is the highest level of diagnostic certainty documented by the doctor.

b.   The codes V01.0 through V82.9 are to deal with visits for circumstances other than disease or injury.


2.   The primary diagnosis should be listed first. Additional codes for any current coexisting conditions are then listed.


3.   ICD-9-CM codes should be listed at their highest level of specificity.

a.   Use three digit codes only if there are no four digit codes within the coding category.

b.   Use four digit codes only if there is no fifth digit subclassification for that category.

c.   Use the fifth digit subclassification for those categories where it exists.


A code with insufficient digits may cause a claim to be returned.


4.   Diagnoses documented as "probable", "suspected", "questionable", or "rule out" should NEVER be coded as if they were confirmed.


5.   When patients receive ancillary diagnostic services ONLY during an encounter, the appropriate "V code" for the service should be listed first, and the diagnosis or problem for which the services are being performed listed second. For example, code V72.5, Radiological examination, not elsewhere classified, describes the reason for the encounter and should be listed first on the claim form or statement. If the reason for the referral is known, a second ICD-9-CM code, which describes the signs, or symptoms for which the examination was ordered should be listed. Failure to list a second ICD-9-CM code in addition to the V code may result in claim delays or denials.


6.   Code all documented conditions that coexist at the time of the visit that REQUIRE OR AFFECT patient care. Do not code conditions that no longer exist.


7.   In the presence of the diagnosis that is the definitive cause of the patient's condition you are prohibited from coding lesser specific diagnoses. If the diagnosis is sprain/strain you NEVER code any symptom, syndrome, radiation or observed factor, such as antalgia. They are automatically included. If you code both the definitive cause and a sign and/or symptom the insurance computer will kick out your billing for review, delaying payment.


8.   Do not code two definitive causes for the same condition, such as a cervical sprain/strain and a cervical subluxation. They are redundant IF you code both definitive causes the insurance computer will kick out your billing for review, delaying payment.


B)   Medicare Penalties For Non-Compliance

The penalties for non-compliance differ depending upon whether or not the health care professional has agreed to accept assignment or not.

1.   For health care professionals who accept assignment on a Medicare claim and who fail to include ICD-9-CM codes as required will have their claim(s) returned for proper coding and may be subject to post-payment review by the Medicare intermediary, as well as payment denials.


2.   For health care professionals who do not accept assignment, the penalties are more severe.

a.   If the original claim form does not include ICD-9-CM codes, as required, and the health care professional refuses to provide the codes promptly on request to the Medicare intermediary, the professional may be subject to a civil monetary penalty in an amount not to exceed $2,000.00, per claim.

b.   If the health care professional continuously fails to provide the ICD-9-CM codes as requested, the professional may be barred from participation in the Medicare program for a period not to exceed five years.



3.   For Medicare the service must be manual manipulation of the spine. This service is reported by the procedure codes for chiropractic manipulation.


4.   The primary diagnosis must be subluxation of the spine, either so stated or identified by a term descriptive of the subluxation. The following diagnoses are acceptable because they would always involve a subluxation (at least according to the reference text):

intervertebral disc disorders   722.0-   722.9

curvatures of the spine   737.0-   737.9

spondylolisthesis   738.4-   756.12

nonallopathic lesions   739.1-   739.4

spondylolysis   756.11


5.   The level of subluxation must be stated.


Down Coding

Down coding is the process of reducing a code from one of a higher value to one of a lower value which results in lower reimbursement.

With procedure coding, down coding claims is easily resolved by providing a procedure description which matches that of Current Procedural Terminology (CPT) exactly, or, even better, by eliminating all procedure descriptions. For Medicare anyway.

A key point to remember is that if there are any current coexisting conditions which may COMPLICATE THE TREATMENT FOR THE PRIMARY CONDITION, it is very important to include the ICD-9-CM codes for the coexisting conditions which will help to justify the level of service provided.

When you use a screening code from the V-code section you should also code signs or symptoms. The reason is most health insurance carriers do not provide coverage for routine screening procedures or preventive medicine.


Coding Injuries

Categories 800-959 include fractures, dislocations, sprains and various other types of injuries. Injuries are classified first according to the general type of injury and within each type there is a further breakdown by anatomical site.

In cases of multiple injuries, the most severe injury is the principal diagnosis. Use the appropriate E-Code to identify the cause of the injury.


Manifestations

Manifestations are characteristic signs or symptoms of an illness. Signs and symptoms that point rather definitely to a given diagnosis are assigned to the appropriate chapter of ICD-9-CM. However, Chapter 16, encompassing categories 780-799, includes ill-defined conditions and symptoms that may suggest two or more diseases or, may point to two or more systems of the body, and are used in cases lacking the necessary study to make a final diagnosis.

Examples:

1.   Cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated, for example, code 784.0 Headache.

2.   Signs or symptoms existing at the time of the initial encounter that proved to be transient and whose cause could not be determined, for example, code 780.2 Syncope and Collapse.

3.   Provisional diagnoses in a patient who failed to return for further investigation or care, for example, code 786.52 Painful Respiration.


Using "V" Codes

V-codes are used to identify encounters with the health care setting for reason other than an illness or injury, for example, immunization. V-codes are also used to identify encounters of persons who are injured or ill and whose injury or illness is influenced by some circumstance or problem classified to the

V-codes fall into one of three categories; Problems, Services or Factual.

1.   Problem: V-codes identify a circumstance or problem that could affect a patient's overall health status but is not itself a current illness or injury. Coding a drug allergy is an example.

2.   Service: V-codes describe circumstances other than an illness or injury, which prompt the patient's visit. This type of visit often occurs when the patient has a chronic disease but is not acutely ill. An example would be a patient with a known disc herniation who has sought a maintenance spinal manipulation.

3.   Factual: V-codes are used to describe certain facts that do not fall into the "problem" or "service" categories. For example, coding the type of birth using code V30.1 - Single Liveborn prior to admission to hospital.


V-codes can be used as a solo code, a principal code or as a secondary code. It is important to use V-codes properly. If a complication is present, the complication should be coded to categories 001-799 instead of to a V-code.


Using "E" Codes

E-codes permit the classification of environmental events, circumstances and conditions as the cause of injury, poisoning and other adverse side effects. The use of E-codes together with the code identifying the injury or condition provides additional information of particular concern to industrial medicine, insurance carriers, national safety programs and public health agencies.

The E-codes may be assigned with any of the codes in the main classification 001-999 to identify the external cause of an injury or condition. E-codes are NEVER used as solo codes or as principal diagnostic codes.

E-codes are important for providing details of an accident to an insurance company to enable them to issue faster and more accurate reimbursement. Since most insurance carriers wait to be sure they reimburse only for services covered under their policy and not for services covered under Worker's Compensation or Automobile/Homeowner's insurance. A clear understanding of the circumstances will eliminate questions from the insurance carrier which cause delays in reimbursements.

When using E-codes always list the E-codes as secondary or supplemental to the code(s) describing the injury.

Coding Example: Fractured ribs due to fall from ladder at home.

807.00 Fracture of ribs, closed, unspecified

E881.0 Fall from ladder

E849.0 Place of occurrence, home



Coding Late Effects

You use late effects coding when coding diagnostic statements that identify a residual effect (condition produced) after the acute phase of an illness or injury has ended. The proper coding sequence is the code number identifying the residual (the current condition) to be listed first with the code number identifying the cause (original illness/injury no longer present in its acute phase but which was the cause of the long term residual condition listed second. An appropriate late effects E Code should be used, where possible, for injuries. Other late-effects codes may be found in the Miscellaneous section (905-909).

Be sure to distinguish between a late effect and a historical statement in a diagnosis. Whenever the statement uses the terms "effects of old...," "sequela of...," or "residuals of...," then code as late effects. If the diagnosis is expressed in terms as "history of...," these are coded to personal history of the illness or injury and are coded to the V-Codes (V-10 to V-19).


Acute and Chronic Coding

1.   If there are separate sub-entries for acute, subacute and chronic, then use both codes sequencing the code for the acute condition first.

2.   If there are no sub-entries to identify acute, subacute or chronic, ignore these adjectives when selecting the code for the particular condition.

3.   If a certain condition is described as a subacute condition and the index does not provide a subentry designating subacute, then code the condition as if it were acute.



In patient's with multiple separate injuries, each separate injury must have a completely separate diagnostic statement. Code the most serious injury first.


ICD-10 Codes

Many have expressed interest in the changeover date from the ICD-9-CM codes to the ICD-10 codes. The Health Care Financing Administration (HCFA) official position is that they will not be mandated for Medicare claims until "at least the year 2000." You should hope they are never used, they are awful.


Abbreviations

NOS
Not Otherwise Specified. Equivalent to Unspecified. This abbreviation refers to a lack of sufficient detail in the statement of diagnosis to be able to assign it to a more specific subdivision within the classification.

NEC Not Elsewhere Classified. Used with ill-defined terms to alert the coder that a specific form of the condition is classified differently. The category number for the term including the NEC is to be used only when the coder lacks the information necessary to code the term to a more specific category.

NOS and NEC codes are vague and non-specific and should not be used to support manipulation, which does require specific knowledge of the exact spinal level. Example: segmental or somatic dysfunction.

Each office should have a copy of the current year's ICD-9-CM, and a copy of the CPT code books. These may be ordered by calling 1-800-MED-SHOP. Ask for ICD-9-CM Hospital Edition, Volumes 1,2 & 3 (1 book), Color Coded and thumb indexed and the current year's CPT code book, Professional Edition. Another excellent book to have is the "Reimbursement Manual For The Medical Office: A Comprehensive Guide To Coding, Billing & Fee Management", Third Edition. I recommend the yearly purchase of the ICD & CPT books.

Since we chiropractors manipulate the articulations of the body the only diagnoses that would support our manipulation would have to be descriptive of a misalignment. Remember, the DIAGNOSIS MUST SUPPORT THE PROCEDURE. OA & DDD complicate a patient's condition but it is the misalignment (subluxation) that we manipulate. Stick to using diagnosis codes you can defend.

Note For California Chiropractors: The Industrial Medical Council has officially defined subluxation and sprain/strain to be acute conditions. Then they defined acute as being within the first thirty days from the date of injury. Get in the habit of going from acute diagnoses to chronic diagnoses before the thirtieth day after the date of injury or you may end up losing a lot of money when the comp carriers finally realize it. You cannot go back and change your past records.(e.g., your billing or diagnosis codes)

A chiropractor should NEVER EVER assign a diagnosis code that describes a sign or symptom. ALWAYS end the diagnostic coding statement with an E code, sometimes two E codes.

Bonus Note!   Do not assign a new patient code unless the patient meets the following definition.
NEW PATIENT:   A patient who has not been seen by a doctor of the same type in that clinic within the last three years. If the patient was seen in that clinic within the last three years s/he is a continuing patient (99211-99215).

I worked with the California Attorney General's office at the request of the SBCE. The Attorney General, and several District Attorneys, are now prosecuting for incorrect use of the Evaluation & Management codes. The MOST IMPORTANT criteria to consider when selecting a code are the CHIEF COMPLAINT. It is NOT the time spent. In order to use higher than a level 1 code the complicating factors that put the patient at increased risk of increased morbidity or mortality must be described and investigated.



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