Question: I am typically paid by insurance with no problems, and always include neck and back pain, being that covers 95 percent of the symptoms I see. However, I have had a slew of denials recently, with the denial indicating that my diagnosis is incorrectly coded per the ICD-10 guidelines. What am I doing wrong?
This question has been asked a number of times in the past year by members of our H.J. Ross Insurance Information Network, with claims being denied for this very reason. A few issues can be behind this.
Least Likely: Incomplete Diagnosis
The simplest, but least likely reason is that you are using an incomplete diagnosis for lower back pain. Lower back pain was updated in October 2021 with three new codes, and instead of the LBP code being four characters in length, M54.5, it was updated to include greater specificity and updated to M54.50, M54.51 and M54.59.
If you are still using the outdated code, the simple fix is to use one of the new codes. However, I assume you are already aware of that change.
Common: Inappropriate Code Combos
The common culprit for this denial in chiropractic claims is when you use code combinations that are forbidden to be coded on the same claim – referred to as diagnosis "excludes."
The ones of greatest concern are called "Excludes 1" codes, which strictly forbid the combination of codes on the same claim. Spinal pain has some very specific rules in terms of which codes cannot be used with spine pain. Based on your statement, I see this as the reason for your denials.
Lower back pain (M5450-M54.59), neck pain (M54.2) or thoracic spine pain (M54.6), and any spine pain code at any level, may not be coded when there is a diagnosis of a disc condition to the spine. I see this come up often on chiropractic billing when the patient has been diagnosed with a disc disorder and the provider adds spine pain along with the disc code.
When that is done, the claim will automatically be denied, as spinal pain with the disc is considered an Excludes 1 and thus cannot be on the same claim.
The logic is simple: There is no need to indicate pain when you have a disc condition, as it may or could be considered inherent. Pain codes are to be used when there is no definitive diagnosis to indicate what is causing the pain. There is no added value or need to indicate pain to a region where you have already indicated an injury, such as a sprain or strain.
By coding convention, you may code disc or pain of the spine alone, but never in combination. If there is a disc diagnosis, that would be the most definitive and appropriate code, as it provides delineation and specificity of the condition; and a clearer picture of a care plan than simply pain.
Excludes for Spinal Pain
Here is a list of excludes for spinal pain codes to help ensure you do not combine them on a claim. Note that thoracic and lumbar spine pain also includes sprains and strains.
While these are the most common and likely will fix your issue, there are others to be aware of to avoid similar denials. Do not combine codes that are muscle in origin on the same claim. For example, if you code myalgia, fibromyalgia, myositis, or muscle spasm, use only one, not a combination.
The same holds with spinal nerve conditions such as radiculopathy, neuritis and nerve plexus disorders. For example, you would never code cervical radiculopathy M54.12 with cervicobrachial syndrome M53.1; it would be one or the other.
Excludes 1 (and 2) Notes
An Excludes 1 note indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note. These Excludes 1 notes can be found throughout the ICD-10 CM codebook, either at the beginning of a code block that pertains to all codes in that block, or on the specific code itself.
A note indicates when two conditions cannot occur together or are mutually exclusive (i.e., not coded here). Simply make the correction and send in the corrected claim.
Note: If you have a code that has an "Excludes 2" note, this indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes 2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.
Editor's Note: Have a billing question? Submit it via email to Sam at sam@hjrossnetwork.com. Your question may be the subject of a future column. Note that submission of a question is acknowledgment that it may be referenced (anonymously) in his column.
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