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3/28/2016
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Strategies for Documenting ICD-10:
Spinal Conditions
Presented by Evan M. Gwilliam, DC MBA BS
CPC CCPC NCICS CCCPC CPC-I MCS-P CPMA
Dr. Evan Gwilliam• Education
• Bachelor’s of Science, Accounting - Brigham Young University
• Master’s of Business Administration - Broadview University
• Doctor of Chiropractic, Valedictorian - Palmer College of Chiropractic
• Certifications• Certified Professional Coder (CPC) - AAPC
• Nationally Certified Insurance Coding Specialist (NCICS) - NCCT
• Certified Chiropractic Professional Coder (CCPC) - AAPC
• ChiroCode Certified Chiropractic Professional Coder (CCCPC) - ChiroCode
• Certified Professional Coder – Instructor (CPC-I) - AAPC
• Medical Compliance Specialist – Physician (MCS-P) - MCS
• Certified Professional Medical Auditor (CPMA) – AAPC, NAMAS
• Certified ICD-10 Trainer - AAPC2
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1. Find an ICD-10 category (three characters) you will frequently use
2. Identify the fourth character descriptions and note key differences
3. Identify the fifth character description (if applicable) for each four-character subcategory and note key differences
4. Do the same for the sixth character (if applicable)
5. Check the guidelines at each level:1. Code
2. Subcategory
3. Category
4. Block
5. Chapter
ICD-10 code breakdown
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1. Find an ICD-10 category (three characters) you will frequently use
2. Identify the fourth character descriptions and note key differences
3. Identify the fifth character description (if applicable) for each four-character subcategory and note key differences
4. Do the same for the sixth character (if applicable)
5. Check the guidelines at each level:1. Code
2. Subcategory
3. Category
4. Block
5. Chapter
ICD-10 code breakdown
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9
Tab
ula
r L
ist
1. Find an ICD-10 category (three characters) you will frequently use
2. Identify the fourth character descriptions and note key differences
3. Identify the fifth character description (if applicable) for each four-character subcategory and note key differences
4. Do the same for the sixth character (if applicable)
5. Check the guidelines at each level:1. Code
2. Subcategory
3. Category
4. Block
5. Chapter
ICD-10 code breakdown
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11
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ist
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13
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ist
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1. Find an ICD-10 category (three characters) you will frequently use
2. Identify the fourth character descriptions and note key differences
3. Identify the fifth character description (if applicable) for each four-character subcategory and note key differences
4. Do the same for the sixth character (if applicable)
5. Check the guidelines at each level:1. Code
2. Subcategory
3. Category
4. Block
5. Chapter
ICD-10 code breakdown
16
Tab
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ist
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1. Find an ICD-10 category (three characters) you will frequently use
2. Identify the fourth character descriptions and note key differences
3. Identify the fifth character description (if applicable) for each four-character subcategory and note key differences
4. Do the same for the sixth character (if applicable)
5. Check the guidelines at each level:1. Code
2. Subcategory
3. Category
4. Block
5. Chapter
ICD-10 code breakdown
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Excludes ***Different in ICD-10***
Excludes1 – is used when two conditions cannot occur together or “NOT CODED HERE!” Mutually exclusive codes; two conditions that cannot be reported together.
Excludes2 – indicates “NOT INCLUDED HERE.” Although the excluded condition is not part of the condition, it is excluded from, a patient may have both conditions at the same time. The excluded code and the code above the excludes can be used together if the documentation supports them.
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ICD-10 Conventions
Excludes
Excludes1 – consider these codes instead
(you can only use 1)
(mutually exclusive)
Excludes2 – consider
these codes in addition
(you may use 2 or more)
(Not included)
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ICD-10 Conventions
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1. Find an ICD-10 category (three characters) you will frequently use
2. Identify the fourth character descriptions and note key differences
3. Identify the fifth character description (if applicable) for each four-character subcategory and note key differences
4. Do the same for the sixth character (if applicable)
5. Check the guidelines at each level:1. Code
2. Subcategory
3. Category
4. Block
5. Chapter
ICD-10 code breakdown
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1. The condition
2. The forward and backward General Equivalence Mappings (GEMs)
3. Helpful information
4. The applicable guidelines at each level:•Chapter
•Block
•Category
•Subcategory
•Code
5. The information conveyed by the 3rd character
6. The information conveyed by the 4th character, if applicable
7. The information conveyed by the 5th character, if applicable
8. The information conveyed by the 6th, and if applicable, 7th character
Provider Documentation Guides
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Provider Documentation Guide
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Provider Documentation Guide
1. The condition
2. The forward and backward General Equivalence Mappings (GEMs)
3. Helpful information
4. The applicable guidelines at each level:•Chapter
•Block
•Category
•Subcategory
•Code
5. The information conveyed by the 3rd character
6. The information conveyed by the 4th character, if applicable
7. The information conveyed by the 5th character, if applicable
8. The information conveyed by the 6th, and if applicable, 7th character
Provider Documentation Guides
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1. Nerve related disorders (e.g. radiculopathy)
2. Acute injuries (e.g. sprains and strains)
3. Structural diagnoses (e.g. degenerative disc disease)
4. Functional diagnoses (e.g. difficulty with walking)
5. Soft tissue problems (e.g. myalgia)
6. Symptoms (e.g. neck pain)
7. Complicating factors/comorbidities (e.g. diabetes)
8. External causes (e.g. place and activity)
Diagnosis Hierarchy
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Sample caseRelevant history: Patient presents with central neck pain and muscle tightness of gradual onset. She works as an engineer and sits at a desk all day, staring at a computer screen.
Relevant exam findings: Acute involuntary contraction is evident in cervical paraspinal muscles and upper traps bilaterally. Restricted intersegmental motion C4/C5. X-ray reveals military neck from C2 to T2.
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
Notes:
• “segmental dysfunction”, not “subluxation”
• “cervicalgia”, not “neck pain”
• “postural kyphosis”, not “military neck”
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
Alp
hab
etic
In
dex
34
Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
Co
mm
on
Co
des
Lis
t-C
hea
t S
hee
t
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35
Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
Co
mm
on
Co
des
Lis
t-A
nat
om
ic
Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
36Tab
ula
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M99.01 Segmental and somatic dysfunction, cervical region
Note: M99.1- subluxation complex (vertebral) S13.1*0_, cervical vertebral subluxationwere not documented here
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
38Alp
hab
etic
In
dex
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
39Co
mm
on
Co
des
Lis
t-C
hea
t S
hee
t
Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
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Co
mm
on
Co
des
Lis
t-C
on
dit
ion
-bas
ed
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41
Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
Tab
ula
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M99.01 Segmental and somatic dysfunction, cervical region
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
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M99.01 Segmental and somatic dysfunction, cervical region
M54.2 Cervicalgia
Note:
“neck pain” does not appear in the alphabetic index, but “cervicalgia” does.
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
Alp
hab
etic
In
dex
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45
Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
Co
mm
on
Co
des
Lis
t-C
on
dit
ion
-bas
ed
Provider Documentation Guide
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Provider Documentation Guide
M99.01 Segmental and somatic dysfunction, cervical region
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
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M99.01 Segmental and somatic dysfunction, cervical region
M54.2 Cervicalgia
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
M99.01 Segmental and somatic dysfunction, cervical region
M54.2 Cervicalgia
M62.838 Other muscle spasm
Note:M62.830 muscle spasm of back
is what should be used for thoracic or lumbar spasm
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
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51
Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
Co
mm
on
Co
des
Lis
t-C
hea
t S
hee
t
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Tab
ula
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
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M99.01 Segmental and somatic dysfunction, cervical region
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
M99.01 Segmental and somatic dysfunction, cervical region
M54.2 Cervicalgia
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
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M99.01 Segmental and somatic dysfunction, cervical region
M54.2 Cervicalgia
M62.838 Other muscle spasm
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Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
M99.01 Segmental and somatic dysfunction, cervical region
M54.2 Cervicalgia
M62.838 Other muscle spasm
M40.03 Postural kyphosis, cervicothoracic region
Note:There are no codes that describe “hypolordosis” or “military neck” 56
Diagnostic statement: Patient suffers from segmental dysfunction at C4, cervicalgia, and muscle spasm of the neck, complicated by postural kyphosis.
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A, D, and S
The seventh character (encounter):
• A – initial encounter, while patient is receiving active treatment including continuing treatment by the same or a different physician
• D – subsequent encounter, routine care during the healing or recovery phase, such as aftercare and follow up
• S – sequela, complications or conditions that arise as a direct result of a condition, such as a scar formation after a burn.
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A, D, and S
The seventh character (encounter):
• A – initial encounter, while patient is receiving active treatment including continuing treatment by the same or a different physician
• D – subsequent encounter, routine care during the healing or recovery phase, such as aftercare and follow up
• S – sequela, complications or conditions that arise as a direct result of a condition, such as a scar formation after a burn.
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The seventh character (encounter):
Which character is correct?• Is the patient receiving active treatment? • Is the patient in the middle of a treatment plan?• Has the patient’s condition stabilized?• Is the patient receiving supportive care?• Is the patient in a healing or recovery phase?• Is the patient being treated for a complication that is the
direct result of some other condition that is no longer present?
General Coding Guidelines
AA
DD
D
S
Sample caseRelevant history: Patient presents with generalized thoracic and lumbar pain after her snowmobile struck a snow bank in the woods at high speeds. Patient reports increased pain at L3 with extension and prolonged sitting. It improves throughout the day and with movement.
Relevant exam findings: Thoracic and lumbar muscle pain during isometric muscle contraction, as well as during passive assisted motion. Tenderness and swelling is evident over L3/L4 facet joints, with palpable right rotation of the L3 spinous process.
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Evidence of sTrain
Evidence of sPrain
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Sample caseRelevant history: Patient presents with generalized thoracic and lumbar pain after her snowmobile struck a snow bank in the woods at high speeds. Patient reports increased pain at L3 with extension and prolonged sitting. It improves throughout the day and with movement.
Relevant exam findings: Thoracic and lumbar muscle pain during isometric muscle contraction, as well as during passive assisted motion. Tenderness and swelling is evident over L3/L4 facet joints, with palpable right rotation of the L3 spinous process.
61
Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
62
Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
S33.130A Subluxation of L3/L4 lumbar vertebra, initial encounter
M53.86 Other specified dorsopathy, lumbar region
S29.012A Strain of muscle and tendon of back wall of thorax, initial encounter
S23.3XXA Sprain of ligaments of thoracic spine, initial encounter
S39.012A Strain of muscle, fascia, and tendon at lower back, initial encounter
V86.52XA Driver of snowmobile injured in nontraffic accident
Y92.821 Forest as place of occurrence of the external cause
Y93.29 Activity, other involving ice and snow
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63
Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
S33.130A Subluxation of L3/L4 lumbar vertebra, initial encounter
64
Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
M53.86 Other specified dorsopathy, lumbar region
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65
Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
S29.012A Strain of muscle and tendon of back wall of thorax, initial encounter
66
Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
S23.3XXA Sprain of ligaments of thoracic spine, initial encounter
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67
Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
S39.012A Strain of muscle, fascia, and tendon at lower back, initial encounter
68
Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
S33.130A Subluxation of L3/L4 lumbar vertebra, initial encounter
S33.5XXA Sprain of ligaments of lumbar spine, initial encounter
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Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
V86.52XA Driver of snowmobile injured in nontraffic accident, initial encounter
70
Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
Y92.821 Forest as place of occurrence of the external cause
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71
Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
Y93.29 Activity, other involving ice and snow
72
Diagnostic statement: Patient suffers from subluxation at L3/L4 with facet syndrome. In addition, there is evidence of strain of the muscles of the back wall of the thorax and lower back, as well as sprain of the ligaments of the thoracic and lumbar spine. Patient is now in active treatment. Patient was the driver of a snowmobile in the forest in a non-traffic accident.
S33.130A Subluxation of L3/L4 lumbar vertebra, initial encounter
M53.86 Other specified dorsopathy, lumbar region
S29.012A Strain of muscle and tendon of back wall of thorax, initial encounter
S23.3XXA Sprain of ligaments of thoracic spine, initial encounter
S39.012A Strain of muscle, fascia, and tendon at lower back, initial encounter
V86.52XA Driver of snowmobile injured in nontraffic accident,initial encounter
Y92.821 Forest as place of occurrence of the external cause
Y93.29 Activity, other involving ice and snow
