As chiropractors, we observe signs and symptoms as colors on an artist’s palette, melding them together to determine how they affect the speed, fluency, quality, and ease of activities of daily living. We communicate this vision to our patients in a report of findings. However, converting that vision into the International Classification of Diseases Clinical Modification (ICD-CM) coding language presents challenges.
Accurate and specific diagnosis coding is crucial in the health care industry. It ensures proper reimbursement for providers and facilitates effective communication among health care professionals. The challenge of translating clinical language into accurate and specific diagnosis codes often befuddles many of us. With that said, let’s explore the difficulties physicians and coders face, and provide tips and strategies to communicate a diagnosis condition to the highest specificity.
Even if one consults a certified professional coder, the coder often lacks the clinical training required to take a variety of terms and acronyms and translate them into the appropriate diagnosis codes. Since 2015, the ICD codes published by the World Health Organization (WHO) have evolved with increased specificity to incorporate a coding system to describe diseases, conditions and treatments.
The United States developed a clinical modification of the ICD codes, ICD-10-CM, to be used to communicate the conditions’ circumstances and determine allowed treatments and medical necessity. Failure to educate oneself on the latest terminology and guidelines can lead to inaccurate coding, which may have serious consequences such as delayed or denied reimbursement.
Physicians and coding staff should adopt the following tips and strategies to overcome these challenges and communicate a diagnosis condition to the highest specificity.
Avoid Signs & Symptoms Codes
Codes that describe symptoms and signs are only acceptable if that is the highest level of diagnostic certainty documented by the doctor. Signs and symptoms should not be coded as additional codes if there is a more specific diagnosis you know encompasses the signs and symptoms.
Many chiropractors use a diagnosis of cervicalgia (M54.2). However, they will readily admit that they would never tell a patient in the report of findings that after consultation and examination, they have determined that the patient has neck pain. Yet using this code informs an insurance carrier and anyone else reading the record that all you know is that the patient has neck pain. To arrive at an accurate diagnosis, we as practitioners need to answer the question, “Why does the patient have neck pain?”
Seek Continuing Education
Continuing education will provide evidence-based information that ties in the signs and symptoms of a disease process. The clinician’s ability to provide accurate coding depends on their ability to reason, think and judge, which a lack of experience can limit.
For example, an experienced physician will intuitively know that a patient with an unstable right sacroiliac joint causing sciatica is often associated with a tight piriformis, tight iliotibial band, increased Q-angle, and hyperpronation syndrome of the feet. The challenge comes with translating the conditions into diagnosis codes.
A solution may be M54.41 (sciatica), M62.59 (deconditioning syndrome) and M32.6X1 (pronation of the right foot). There may be alternatives, but this code combination conveys a clearer picture of the condition.
The medical necessity of care is established by conveying a specific picture of the patient’s condition. In the above example, the hyperpronation of the feet and deconditioning have led to the instability of the sacroiliac region, causing sciatica. Therefore, it can be argued that to focus on effective patient treatment, the practitioner must prescribe custom three-arch orthotics and therapeutic rehabilitation with manipulation to treat the entire syndrome effectively. Leaving out one aspect of the solution will lead to prolonged, ineffective care.
Only Use a Diagnosis If Confirmed
Only assign a code to a case if the condition has been confirmed by examination or imaging. Diseases, disorders and conditions that are suspected or that you want to rule out should not be assigned as codes until that condition is verified.
For example, if the practitioner suspects a disc herniation exists, document it in the chart, but until an MRI or CT scan confirms the herniation, the code cannot be put on the claim form. If the patient has low back and leg pain, even though you suspect a disc herniation, you must code what you know, such as lumbago with sciatica (M54.41 or M54.42).
Put Your Codes in Proper Alignment
The order of the codes often determines reimbursement variations. The first code is the most crucial, since the insurance carrier’s software reads a claim from the top down and left to right. Medicare is one of the few carriers that requires a segmental and somatic dysfunction code (M99-) in the first position. Consider putting the segmental and somatic dysfunction code in the second or third position when Medicare or Medicaid is not the primary carrier.
A neurologic disorder will supersede all other conditions if present since it is the most difficult to treat. A structural condition comes next in the hierarchy, followed by functional conditions, soft tissue, extremity, and complicating factors.
Use Coding Resources
Coding resources are like the Rosetta Stone of diagnosis. Admittedly, most books are for medical personnel. There are resources available to chiropractors that will help in the translation process. Chiropractors must utilize coders, coding books and classes, online databases, and coding software to clarify how a chiropractor envisions the whole body from the ground up.
These resources provide coding guidelines, clinical examples and cross-references to assist coders in accurately translating clinical language into specific diagnosis codes. Many state and professional entities strive to bring continuing education to the chiropractor and staff to accomplish this task. When trained together, the doctor and staff can work together as a team to ensure accuracy.
Identify Errors Through Auditing and Quality Assurance
Regular auditing and quality assurance processes can help identify coding errors or discrepancies. It is preferable to utilize a knowledgeable resource who is independent. By reviewing your documentation and billing, a certified individual will proactively provide feedback so you can improve accuracy and ensure consistent coding practices.
We can all agree that having an individual looking out for your best interests, and providing feedback and education, is preferable to a government agency or peer reviewer inspecting your files. Personal coaching with documentation and coding experts in complex cases or situations may be a valuable opportunity to gain experience and grow.
Practice Pearls
Accurate and specific diagnosis coding is a crucial aspect of chiropractic. However, as physicians, we face various challenges when translating clinical language into specific diagnosis codes. By arming yourself with knowledge of coding principles, investing in continuous education, utilizing coding resources, and implementing regular auditing and quality assurance processes, you can overcome these challenges and communicate a diagnosis condition to the highest specificity.
