Chiropractic Coding & Compliance Alert

Keep an eye on what the LCDs reveal.

There has been significant speculation regarding how Medicare will adapt subluxation diagnosis coding for ICD-10. Now chiropractics finally have some clarity regarding this limited subset of codes that demand increased specificity.

The elusive legacy: Medicare requires chiropractors to use the 739 codes for chiropractic subluxations. The ICD-9 code 739 (Nonallopathic lesions, not elsewhere classified) is an elusive diagnosis that neither describes a chiropractic subluxation nor says what condition the patient has; it  just says that there is no code to describe what the patient has. The inclusion note with the code, however, explains that category 739 can include “segmental or somatic dysfunction.”

That said, it is still hard for a non-chiropractic coder to intuitively find the right code for the “subluxation,” as none of the terms in the description for 739 appears in the alphabetic index. The ICD-9 allopathic “subluxation” is more in line with the “partial dislocation” viewpoint, which is usually treated by other providers.

“For the most part, coders have just coded what Medicare wants and will pay that as close to what we can get for diagnosis,” says Elizabeth Earhart, CPC, with Godshall Chiropractic in Millersville, PA.  

“Most payers follow Medicare guidelines so they follow the same limitations,” adds Earhart. “I am constantly arguing with the doctor about what he can and cannot diagnose as per the scope of his license per Medicare guidelines. For example, he wants to diagnose TMJ but that is not a payable ICD-9 code for primary diagnosis and for some payers cannot be in the top four diagnoses for secondary.” 

Make Your Way Through the Maze of Crosswalks

According to GEMs (General Equivalency Mappings), the ICD-9 code of 739.1 (Nonallopathic lesions of cervical region not elsewhere classified), is approximate to M99.01 (Segmental and somatic dysfunction of cervical region). This M99.0- group of codes is listed on the future drafts of most Medicare Local Coverage Determinations. The only difference in the description is that the word nonallopathic is replaced with biomechanical. 

You may explore enough to find another code, M99.11 (Subluxation complex [vertebral] of  cervical region). Don’t get too excited about finding your best answer, because GEMs point this code to an ICD-9 equivalent of 839.00 (Closed dislocation, cervical vertebra, unspecified) instead of the 739 family. The 839 codes are for “other, multiple, and ill-defined dislocations.” 

Root cause: When the GEMs crosswalk was compiled, somehow the chiropractic definition of “subluxation” was left out. Hence, few payers are likely to allow this M99.1- code. 

WCA Throws Light on What To Expect

The Wisconsin Chiropractic Association (WCA) throws some light on how the National Government Services proposes to assist the chiropractor to better describe the condition of the patient.

Here are a few highlights:

• The concept of documenting a “primary code” (i.e., subluxation) with a “secondary code” (other symptom or disease) will stay the same.

• The “primary code” depicting subluxation will change from 739.1-739.5 used presently to M99.01-M99.05 in the future. 

• The “secondary code” choices available have increased three fold, from 71 codes in ICD-9 to 251 codes in ICD-10. This is probably due to the increase in specificity of the codes in ICD-10. “ We have created a spreadsheet with new and old codes by region in order to help both the doctor and myself see how the scope has expanded,” tells Earhart.

• There is a single “A” code related to infectious diseases.

• There are 8 “G” codes related to neurology.

• There are 207 “M” codes related to musculoskeletal conditions, including 26 new biomechanical lesion codes (M99-).

• The congenital diseases are depicted by 8 Q codes.

• There are 27 new S codes denoting acute injury. 

Remember: The primary diagnosis should be subluxation, and should imply the level of the subluxation. The secondary diagnosis should denote the neuromusculoskeletal condition necessitating the treatment.

WCA offers a complete list of primary and secondary codes that apply to you on its website (www.wichiro.org). 

Set All Eyes for the LCDs

Medicare administrative contractors (MACs) release Local Coverage Determinations (LCDs) for chiropractic services just as for other specialties. You can extract useful information on how your MAC will approach ICD-10 from a coding point of view and where you need to work to circumvent potential medical necessity concerns. Most MACs expect the first diagnosis code to be from ICD-9’s category 739. If you are curious for a list of proposed “future” Local Coverage Determinations (LCDs) converted to ICD-10, you can go to the link http://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx.

Remember: LCDs include much more than a listing of diagnosis codes. Each LCD contains a wealth of information on the documentation requirements and the source documents used for reference. That means you can search LCDs to know exactly what your MAC wants documented to demonstrate medical necessity for a particular situation. They usually have a section that lists potential diagnoses for that condition or procedure. 

“LCDs have always come in handy for defending diagnoses and are a great guideline for knowing what a payer will recognize,” advises Earhart. “It is also a great defense when you are denied.  A payer does not like hearing the phrase, ‘According to the LCD…’ because it is the one rule that cannot be argued or changed to suit.”

When all is said and done, remember that correct code selection will always depend on the payer. GEMs are just a guide for practitioners and payers alike. 

As a rough guide, when you submit a diagnosis code listed as supporting medical necessity on the claim form, the payer should accept and reimburse the diagnosis. The underlying idea is that by pursuing the coding guidelines, the diagnosis code on the claim form should ideally accurately represent the patients’ medical condition as documented in their medical record.

Final takeaway:  So, will payers be able to seamlessly apply the existing decision logic to these new codes? You won’t find out until you submit the first claims after the ICD-10 implementation date. We will just have to wait and hope the subluxations chiropractics have been diagnosing all these years will finally be reportable with ICD-10-CM. So your strategy should include “a plan and watch” approach. Be on the lookout for communications from your Medicare carrier and perhaps any commercial payers as well.

“When a payer offers a webinar on its ICD-10 updates, attend it!” decrees Earhart. “It may seem like a rehash from payer to payer of the same thing every time, but you may be surprised to learn that payer 1 may have a different approach than payer 2 that might be of use to you or that you can question because it is different.  Payers need input from our offices to make their transitions easier also.

---