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1 ICD-10 Utilization in the NEW World With Mario Fucinari DC, CCSP, CPCO, MCS-P, MCS-I Presented by NCMIC The information contained in these notes is for educational purposes and is not intended to be and is not legal advice. Disclaimer: The views and opinions expressed in this presentation are solely those of the author. We do not set practice standards. We offer this only to educate and inform This Material is Copyright Protected NO RECORDING OF ANY TYPE ALLOWED Unauthorized Audiotaping or Videotaping or Distribution of any presentation materials is illegal. LEGAL NOTICE: The information contained in this workbook is for educational purposes and is not intended to be and is not legal advice. Audiotaping and/or videotaping are strictly PROHIBITED during the presentations. The laws, rules and regulations regarding the establishment and operation of a healthcare facility vary greatly from state to state and are constantly changing. Mario Fucinari DC does not engage in providing legal services. If legal services are required, the services of a healthcare attorney should be attained. The information in this class workbook is for educational purposes only and should not be construed as written policy for any federal or state agency. All clinical examples are based on true stories. The patient names in the clinical examples have been changed to protect the innocent. No part of this workbook covered by the copyright herein may be reproduced, transmitted, transcribed, stored in a retrieval system or translated into any language in any form by any means (graphics, electronic, mechanical, including photocopying, recording, taping or otherwise) without the expressed written permission of Mario Fucinari DC. Making copies of this seminar workbook and distributing for profit or non-profit is ILLEGAL. Mario Fucinari DC assumes no liability for data contained or not contained in this workbook and assumes no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this seminar workbook. CPT is a registered trademark of the AMA. The AMA does not directly or indirectly assume any liability for data contained or not contained in this seminar workbook. This seminar workbook provides information in regard to the subject matter covered. Every attempt has been made to make certain that the information in this seminar workbook is 100% accurate, however it is not guaranteed. 1

2 About Dr. Mario Fucinari, DC, CCSP, CPCO, MCS-P, MCS-I President of Mario Fucinari DC Compliance Consulting, LLC Graduate of Palmer College of Chiropractic Currently in Full Time Practice in Decatur, Illinois Certified Chiropractic Sports Physician (CCSP) Logan College of Chiropractic Certified Insurance Consultant - Logan College of Chiropractic Certified Medical Compliance Specialist Physician Medical Compliance Training 2007 Certified Professional Compliance Officer CPCO (AAPC) Post-graduate Faculty of Palmer College of Chiropractic, NYCC, D Youville College, Life West and Western States Chiropractic College National Speaker s Bureau for NCMIC and Foot Levelers and many state associations Past President of Illinois Chiropractic Society (ICS) Chairman, ICS Medicare Committee Member Medicare Carrier Advisory Committee ICS Chiropractor of the Year 2012 Member of ACA and ICS New information posted regularly at and Like us ICD-10 Coding and Documentation History of ICD The World Health Organization (WHO) controls the international classification of diseases (ICD). The ICD has been revised and published in a series of editions to reflect advances in health and medical science over time. ICD is the foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions. It is the diagnostic classification standard for all clinical and research purposes. ICD defines the universe of diseases, disorders, injuries and other related health conditions, listed in a comprehensive, hierarchical fashion that allows for: - easy storage, retrieval and analysis of health information for evidenced-based decision-making; - sharing and comparing health information between hospitals, regions, settings and countries; and - data comparisons in the same location across different time periods. Uses include monitoring of the incidence and prevalence of diseases, observing reimbursements and resource allocation trends, and keeping track of safety and quality guidelines. They also include the counting of deaths as well as diseases, injuries, symptoms, reasons for encounter, factors that influence health status, and external causes of disease. 2

3 ICD-10 Freeze ended October 1, Convert to Phase 2 Comparisons of ICD-9 to ICD-10 ICD-9 Diagnostic Codes ICD-10 Diagnostic Codes 3-5 Characters in length 3-7 Characters in length Approximately 17,000 codes First digit may be alpha; 2 nd through 5 th is numeric Limited space for adding new codes Lacks detail Lacks laterality Difficult to analyze data due to non-specific codes Codes are non-specific and do not adequately define diagnoses needed for medical research Does not support interoperability because it is not used by other countries Approximately 70,000 available codes Character 1 is alpha; character 2 and 3 are numeric; character 4 through 6 can be either Flexible for adding new codes Very specific Has laterality Specificity improves coding accuracy and quality of data for analysis Detail improves the accuracy of data used for medical research Supports interoperability and the exchange of health data between other countries and the U.S. ICD-10 Phase 2 went into effect October 1, new ICD-10 codes added 422 revisions 305 deleted codes ICD-10-CM The increased specificity of the ICD-10 codes requires more detailed clinical documentation in order to code some diagnoses to the highest level of specificity There are unspecified codes in ICD-10-CM for those instances when the health record documentation is not available to support more specific codes The benefits of ICD-10 cannot be realized if non-specific codes are used rather than taking advantage of the specificity ICD-10 offers 3

4 Quality Measure Reporting Must try to achieve improvement in your practice profile Your first line of communication with the carrier is your claim form What are you communicating? Choose your diagnoses wisely! Data Analysis Aging Baby Boomers Increased Co-morbidities Complications to Care Patient Responsibility for Outcomes Population Health Management Past actions yield future payment adjustments What are your local carriers telling you? ICD-10 Step to UPDATE 1. Gather your last 40 new patient s charts 2. Make a list of the ICD-10 diagnoses 3. You have your Top 40 Playlist 4. Check your EOBs 5. Identify Unspecified Codes and Deleted Codes 6. Convert to 2017 Code Usage 4

5 Quality Reporting System Under MIPS 2017 In 2017, TWO of the measures must be reported by many chiropractors: 1. Pain Assessment # Functional Outcomes Assessment #182 PQRS # 131 Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present Standardized Tool An assessment tool that has been appropriately normalized and validated for the population in which it is used. Examples of tools for pain assessment, include, but are not limited to: Brief Pain Inventory (BPI), Faces Pain Scale (FPS) (for mentally disabled) McGill Pain Questionnaire (MPQ) Multidimensional Pain Inventory (MPI) Neuropathic Pain Scale (NPS) Numeric Rating Scale (NRS) Oswestry Disability Index (ODI) Roland Morris Disability Questionnaire (RMDQ) Verbal Descriptor Scale (VDS) Verbal Numeric Rating Scale (VNRS) a.k.a. Borg scale Visual Analog Scale (VAS). Follow-Up Plan Proposed outline of treatment to be conducted as a result of pain assessment. Follow-up must include a planned reassessment of pain and may include documentation of future appointments, education, referrals, pharmacological intervention, or notification of other care providers as applicable. The documented follow-up plan must be related to the presence of pain. Return next visit for re-assessment of pain Associated Follow-up Options: Follow-up appointment, Referral, Notification to another provider, OR indicate the initial treatment plan is still in effect. Not Eligible A patient is not eligible if one or more of the following reasons exist: 5

6 - Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example, cases where pain cannot be accurately assessed through use of nationally recognized standardized pain assessment tools. - Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient s health status. Pain Assessment Codes to use: Performance Met: Pain assessment documented as positive using a standardized tool AND a follow-up plan is documented. Performance Met: Pain assessment documented as negative, no follow-up plan required Performance Exclusion: Documentation that patient is not eligible for a pain assessment OR Performance Exclusion: Pain assessment documented, follow-up plan not documented, patient not eligible/appropriate Performance Not Met: NO documentation of pain assessment, reason not given OR Performance Not Met: Documentation of positive pain assessment; no documentation of a follow-up plan, reason not given G8730 G8731 G8442 G8939 G8732 G AT A XX.XX G8730 A.01 6

7 PQRS # 182 Functional Outcome Assessment: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies Measure #182, the Functional Outcome Assessment measure, has an additional definition for quality data code G8942, which now is reported to reflect functional outcome assessment documented, no functional deficiencies identified, care plan not required, or functional outcome assessment and care plan documented in the previous 30 days. DESCRIPTION: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies INSTRUCTIONS: This measure is to be reported each visit indicating the appropriate numerator code; however, the assessment is required to be current as defined for patients seen during the reporting period. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Documentation of a current functional outcomes assessment must include identification of the standardized tool used. Clarification: The intent of the measure is for the functional outcome assessment tool to be utilized at a minimum of every 30 days but reporting is required at each visit due to coding limitations. Therefore, for visits occurring within 30 days of a previously documented functional outcome assessment, the numerator quality-data code G8942 should be used for reporting purposes. Measure Reporting via Claims: CPT codes and patient demographics are used to identify patients that are included in the measure s denominator. G-codes are used to report the numerator of the measure. When reporting the measure via claims, submit the listed CPT codes, and the appropriate numerator G- code. All measure-specific coding should be reported on the claim(s) representing the eligible encounter. Measure Reporting via Registry: CPT codes and patient demographics are used to identify patients who are included in the measure s denominator. The numerator options as described in the quality-data codes are used to report the numerator of the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. DENOMINATOR: All visits for patients aged 18 years and older 7

8 Denominator Criteria (Eligible Cases): Patients aged on date of encounter AND Patient encounter during the reporting period (CPT): 97001, 97002, 98940, 98941, Definitions: Standardized Tool An assessment tool that has been appropriately normalized and validated for the population in which it is used. Examples of tools for functional outcome assessment include, but are not limited to: Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), Neck Disability Index (NDI), and Patient-Reported Outcomes Measurement Information System (PROMIS). The use of a standardized tool assessing pain alone, such as the visual analog scale (VAS), does not meet the criteria of a functional outcome assessment standardized tool. Functional Outcome Assessment Patient completed questionnaires designed to measure a patient's limitations in performing the usual human tasks of living and to directly quantify functional and behavioral symptoms. Current A patient having a documented functional assessment within the previous 30 days. Functional Outcome Deficiencies Impairment or loss of physical function related to neuromusculoskeletal capacity, may include but are not limited to: restricted flexion, extension and rotation, back pain, neck pain, pain in the joints of the arms or legs, and headaches. Care Plan A care plan is an ordered assembly of expected/planned activities or actionable elements based on identified deficiencies. These may include observations goals, services, appointments and procedures, usually organized in phases or sessions, which have the objective of organizing and managing health care activity for the patient, often focused on one or more of the patient s health care problems. Care plans may also be known as a treatment plan. Not Eligible A patient is not eligible if the following reasons(s) exist: - Patient refuses to participate - Patient unable to complete questionnaire Oswestry Disability Index (ODI) Revised Oswestry Low Back Pain Disability Questionnaire Roland-Morris Disability/Activity Questionnaire (RM) Neck Pain Disability Index Questionnaire (NDI) Physical Mobility Scale (PMS) 8

9 Functional Assessment Performance Met: Documentation of a functional outcome assessment using a standardized tool AND documentation of a care plan based on identified deficiencies on the date of the functional assessment. OR Performance Met: Documentation of a functional outcome assessment using a standardized tool; no functional deficiencies identified, care plan not required OR Performance Met: Documented functional outcome assessment and care plan within the previous 30 days Performance Exclusion: Documentation that the patient is not eligible for a functional outcome assessment Performance Exclusion: Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan Performance Not Met: Functional outcome assessment using a standardized tool not documented, reason not given OR Performance Not Met: Documentation of a functional outcome assessment using a standardized tool; care plan not documented, reason not given Code G8539 G8542 G8942 G8540 G9227 G8541 G8543 Example: (Circle one from each group) Pain Assessment G8730 Pain Assessed, present G8731 Pain assessed, but no pain G8732 Pain NOT assessed Outcomes Assessment (OATS) G8539 OATS done today G8942 OATS not done today; but within the last 30 days G8542 OATS done today; no deficiency G8541 OATS NOT done in the last 30 days General ICD-10 Coding Guidelines: 1. ICD-10-CM codes should be listed at their highest level of specificity and characters. a. ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Use three character codes only if there are no four character codes within the coding category. These are the heading of a category of codes. You will rarely use a three-character code, if ever. b. Diagnosis codes are to be used and reported at their highest number of characters available. Use the 4, 5, 6, or 7-digit code to the greatest degree of specificity available. These provide further detail. 2. Codes that describe symptoms and signs are only acceptable if that is the highest level of diagnostic certainty documented by the doctor. No other diagnosis has been established 9

10 (confirmed) by the provider. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. 3. Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. a. As an example, you would not use a code for muscle spasm along with a strain code, since the finding of spasms are routinely associated with a strain. 4. Additional signs and symptoms that are not routinely associated with a disease may be reported. 5. Coding for diagnoses that are probable, suspected, likely or questionable are not to be coded, because they indicate uncertainty. Code what you know Rule out and working diagnosis are not to be coded. 6. Code all documented conditions that coexist at the time of the visit that REQUIRE OR AFFECT patient care. (complicating factors) Do not code conditions that no longer exist. 7. Coding for diagnoses that are probable, suspected, rule out, etc. are not allowed for outpatients. You can write that you suspect a certain condition in your notes, but the code for it will not go on the claim form. 8. The term first-listed diagnosis is now to be used instead of the term principle diagnosis. Code first notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a code first note and an underlying condition is present, the underlying condition should be sequenced first. Code, if applicable, any causal condition first notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable. If a causal condition is known, then the code for that condition should be sequenced as the principal or first-listed diagnosis. 9. Multiple codes may be needed for sequela, complication codes and obstetric codes to more fully describe a condition. See the specific guidelines for these conditions for further instruction. 10. The acute condition should always be listed first. a. The worst goes first! 10

11 10. Each unique ICD-10 diagnostic code may be reported only once. If you use a left and right code, you only list the diagnosis with these sides once. 11. If the condition is bilateral and there is no bilateral code, then you have to list the left and right code separately. 12. If a condition is borderline, then it is listed as confirmed. 13. An unspecified code should be reported only when it is the code that most accurately reflects what is known about the patient s condition at the time of that particular encounter. 14. It is inappropriate to select a specific code that is not supported by the health record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. Note: There are 21 chapters in the new ICD-10 Classification System. Some of the chapters will never be used by the chiropractor. If you use functional medicine in your practice, I recommend that you take classes that pertain to your area of expertise. ICD-10-CM Conventions The ICD-10 Characters Placeholder X character - The ICD-10-CM utilizes a placeholder character X The X is used as a 5th and /or 6th character placeholder at certain 6 and/or 7-character codes to allow for future expansion. 7th Characters S13.4xxA Sprain of neck, initial encounter Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters. Ordinality Is this the initial or subsequent visit for the complaint? Are these symptoms the sequela of the initial event? 11

12 7th Character Basic ICD-10 Coding Guidelines: A Initial encounter D Subsequent encounter S Sequela 1. 7 th character A: Initial encounter (Medicare says to use this during active care) Used when the patient is receiving active treatment for the condition - CMS says this is used as long as the patient is under active care (-AT modifier) While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time th character D: Subsequent encounter After treatment in the active phase of care and the patient is in the healing or recovery phase of care Examples of this care are cast change, medication adjustment, or other aftercare following treatment of the injury or condition. In chiropractic, this may be used in the phase when the patient is in rehabilitation th character S: Sequela also known as late effects For complication or conditions that arise as a direct result of a condition, such as deconditioning of muscle after an injury. When using the Sequela codes, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The S is added to the injury code only, not the sequela code. The 7 th character S identifies the injury responsible for the sequela. The specific type of sequela is sequenced first on the claim form, followed by the injury code. 12

13 Sequencing of ICD-10 Codes Numbers are reported on the insurance claim form because you are communicating to a computer. Be sure to use the correct numbers, to the highest degree of specificity. This must be supported by the chart documentation. The diagnosis you provide directly relates to the level of care permitted by the third-party payers. Proper Sequencing of Codes in ICD-10 Optimal sequencing of the codes: Neurological diagnosis Structural descriptor diagnosis Functional diagnosis Soft tissue Extremity 13

14 ICD-10 Chapter 13: Rules for Diseases of the Musculoskeletal System and Connective Tissue (M00 M99) Medicare Subluxation Complex Segmental and somatic dysfunction M segmental and somatic dysf.- cervical region M segmental and somatic dysf.- thoracic region M segmental and somatic dysf.- lumbar region M segmental and somatic dysf.- sacral region M segmental and somatic dysf.- pelvic region Simple Coding Examples: ICD-9 Cervicalgia ICD-10 Cervicalgia M54.2 Combination Coding Examples M54.30 Sciatica unspecified side M54.31 Sciatica Right M54.32 Sciatica Left M54.40 Sciatica with lumbago unspecified M54.41 Sciatica with lumbago right M54.42 Sciatica with lumbago left ICD-10-CM Specificity Laterality ICD-10 codes include right or left designations. The right side is usually designated with the character 1, and the left side is designated with the character 2. In cases where a bilateral code is designated, the character 3 may be designated. An unspecified side is either a character 0 or 9 depending on whether it is a fifth or sixth character. Right Side Ends in Number Left Side Ends in Number When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists. The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate. 14

15 Spine is specified by Spinal Coding 0 Multiple sites in spine 1 Occipito-atlanto-axial region Occ-C1-C2 2 Cervical region C3-C6 Deleted 21 C C C6-7 3 Cervicothoracic region C7-T1 4 Thoracic region T2-T11 5 Thoracolumbar region T12-L1 6 Lumbar region L2-L4 7 Lumbosacral region L5-S1 8 Sacral and sacrococcygeal region 9 Site unspecified M Other cervical disc degeneration, mid-cervical region, unspecified level(m50.32) M Other cervical disc degeneration at C4-C5 level (was M50.32) M Other cervical disc degeneration at C5-C6 level (was M50.32) M Other cervical disc degeneration at C6-C7 level (was M50.32) Headache Classic Migraine Migraine with aura Common Migraine Migraine without aura Status Migrainosus Severe migraine that lasts > 72 Hours Chronic Migraine Migraine that occurs > 15 days per month for at least 3 months Persistent Migraine lasts more than 3 months and daily Opthalmoplegic Migraines around the eyes 15

16 ICD-10 Chapter 19: Rules for Injury, Poisoning, and Certain Other Consequences of External Causes (S00 T88) Requires the A, D, or S extension to indicate the phase of care. As of October 1, 2016: Another major change will be requirement to use an external cause of injury code whenever an S Injury Code is used. The exception to this rule appears to be spinal strain and sprain codes. Some carriers may require the external cause codes is the S code is used anywhere in the sequence. Check with your PPO carriers for policy changes. Medicare has not given any indication of this requirement. External Cause codes are always last in the sequence of codes. If the external cause code is required with injury codes, you may be required to indicate if an accidental injury occurred in Box 10. Work injury, Automobile or other. Codes that are indicated with the word ADD, should NOT be used until after 10/1/16. These codes are not present in the current code set. Check with your practice management software company and make sure they are providing you with an update to the code set. Deleted codes should be removed from the database to avoid incorrect billing. If you treat any conditions that involve LATERALITY (right side, left side, bilateral), after 10/1, you MUST indicate laterality, both in the code and in your supporting documentation. In GENERAL, codes with end in 1 for the right side, 2 for the left side and 3 for bilateral. If no bilateral code exists, code BOTH right and left if you are treating a condition bilaterally. The Problem List vs. The Diagnosis List: ICD-10 Chapter 20: External Causes of Morbidity (V00-Y99) ICD-10 External Cause Codes Initial encounters generally require four codes 1. External cause codes Classify as a verb Used for length of the treatment of the patient Utilizes 7 th character extender Changes with the status of the patient 16

17 A, D, S Use the full range of external cause codes to fully explain each cause Assign as many codes as necessary, however if only one is used, use the code that most relates to the principal diagnosis An external cause code can never be a principal (first-listed) diagnosis May be a combination external cause code that identifies sequential events that result in an injury. An example would be a fall that results in striking an object. The combination external cause code used should correspond to the sequence of events regardless which caused the most serious injury. 2. Place of occurrence (Y92) This is a secondary code for use after other external cause codes to identify the location of the patient at the time of injury or other condition. Used only once, at the initial encounter No 7 th character is used Use it only if you know where was the location of the injury Never us an unspecified code here 3. Activity codes (Y93) Used only once, at the initial encounter Use it only if you know what is the activity Only one code from this category is to be listed Never us an unspecified code here Used in conjunction with a place of occurrence code (Y92) 4. External cause status Used only once at the initial encounter Was the patient working at the time of the injury? Military? Hobby? A work-related activity is any activity for which payment or income is derived. Use Y93.9 if the activity of the patient is not stated or is not applicable 17

18 Regardless of the number of external cause codes assigned, there should be only one place of occurrence code and one activity code assigned to an encounter. Helpful Tips for Survival in the NEW World of Coding Cervicalgia and Lumbalgia codes are a last resort! Disc Disorder vs. Disc Displacement Radiculopathy vs. Myelopathy What documentation is needed for the following: Postlaminectomy Syndrome Disc Displacement Degenerative Disc Disease Spina Stenosis Scoliosis Disuse Atrophy 18

19 Sources: CMS ICD-10 Training for Free Footlevelers.com Updates Free Webinars Free Webinars ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office by Dr. Mario Fucinari ICD-10 Coding for Chiropractic from ChiroCode.com New information posted regularly at Like us Put us in your notifications Order Your Chart Baseline Audit If you have questions Doc@AskMario.com Thank You!! 19