Q and A From ICD-10 Coding Webinar

Physical Therapy Coding Q and A
July 6, 2015
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Sessions 1 – 3 / September 2015

The following is a list of the questions submitted by ICD-10 Coding for Physical and Occupational Therapy webinar participants with answers.

When can we begin billing ICD-10 codes?  You cannot file claims with ICD-10 codes before October 1, 2015.  Some carriers will accept dual coding – so you need to check to see what each carrier will allow. However, only ICD-9 codes will support billing through September 2015.  

Medicare will use the ICD-10 system, but workers comp and auto insurance are not required to use ICD-10.  What about the other insurance companies?  All commercial insurance payers will transition to ICD-10 on October 1, 2015.

How do I find an ICD-10 code?  You can use a number of methods, including the following:

  • If you are using an EHR system, you should have a method of looking up an ICD-10 code in your system
  • You can use CMS tools by following the steps in the last FAQ below

Do we code every treatment session? Or just the evaluation? Or the evaluation and then only if the patient’s condition changes and the changes impact PT treatment? Just as in ICD-9, every claim form that is submitted for a patient treatment must have codes that support the treatment. So, yes, there will be ICD-10 codes for every encounter.  Typically, during the evaluation, the therapist identifies the codes. If the focus of the treatment session changes, the codes should change. If the plan of care continues, the codes will typically stay the same.

We get scripts from MDs with no codes.  What if the MD put “unspecified” and we see that this is left on the claim coding?  With ICD-10 coding, there should be no unspecified codes on the claim.  If you are treating the patient, the primary code should reflect what you are treating. So, even if the physician sends an unspecified code, you should find and use a code that provides specifics on what you are treating.

You should have a check and balance system in your clinic so that, if the clinician misses a code and leaves an unspecified code, someone else (e.g., in the billing office) sees that there is an unspecified code and works to get it changed before it goes on the claim.

If our workers compensation payers are not switching to ICD-10, will they accept the ICD-10 diagnosis?  This decision will be state specific; check with the workers comp carrier in your state to ask if they will be accepting ICD-10 codes and, if so, ask the date that they will accept them.  Find out if your EHR system will be able to discern the appropriate code to bill on each claim based on payer information that has been loaded into your system. Some EHR systems can bill both codes, or either ICD-9 or ICD-10, based on how the insurance information is loaded.

Will ICD-10 codes change between encounters, such as acute to chronic or unspecified to specified?  The codes that are on each claim should support the service you are providing. With that said, if the patient’s condition changes from acute to chronic and the focus of the treatment changes, it might be appropriate to update the code. However, if your plan of care for a particular diagnosis is progressing normally, there will probably not be any reason to change the coding.  

You should never start with an unspecified code. If you ask yourself “what is the condition that I am treating”, you should be able to answer that question and find a specified code to support your plan of care.

Does the initial encounter indicate first time receiving treatment for a condition and subsequent encounter indicate a second?  Yes, the initial encounter, identified by the 7th digit “A,” demonstrates the first time the patient received care for this condition.  It is usually only found on injury codes.  So, the “A” will only be used ONE time, by ONE provider. If the patient has seen the physician first, the physician will use the “A” and the therapist will use the “D” for the subsequent encounter.  If the patient sees the physical therapist as direct access, check to see if the patient went to the emergency room; if so, the ER would use the “A”; if not, the PT could use the “A”. The 7th digit “A” is only used by one provider the first time the patient is seen and therefore the “A” code will only rarely be used by therapists.

For episode of care, what are we to code if the patient sees us through direct access? Is the initial encounter used and do we need to change the code on the second visit?   If the patient sees you without being seen by any other healthcare provider (like the emergency room), and you are the first encounter, then, yes you would code your encounter as an initial encounter and enter the “A” as the seventh digit on your initial evaluation date. Starting on the second visit, that primary code would need a change of the 7th digit to “D” for subsequent visit. This would continue for other treatments.

Does the order we list the ICD-10 codes affect payment…most to least relevant?

You always want to list the primary diagnosis code first.  Remember, unspecified codes will trigger a denial.

How do we handle coding for Medicaid patients?  Medicaid will transition to ICD-10 coding on October 1, 2015, in the same manner as Medicare and commercial insurance.  (The V57.1 code will not be used.)  If an aftercare code is appropriate, it will be a “Z” code instead of a “V” code in ICD-10.

If there is not an ICD-10 code for right or left in regards to bilateral conditions, then what do we code? Typically, no codes support “bilateral” conditions.  If you are identifying a bilateral treatment, you would code the left and then the right.  Do not choose unspecified. If you are treating both the right and the left, you will end up using two codes.

For outpatient PT, will or has Medicare indicated if they will be preparing a list of codes that would allow treatment to exceed the cap?  CMS has not made any announcement to this effect and we doubt if they will.  Keep in mind that patient care can exceed the cap as long as it is medically necessary.  We recommend that you continue ensuring that your diagnosis supports the condition you are treating and make sure your documentation supports the medical necessity.  Also, of course, continue to use the KX modifier.

Do we need to code comorbidities or do we only need to mention them in the documentation? You actually need to code comorbidities if they are affecting your treatment. Regardless of the payer, you always want to document to support medical necessity. Definitely do not forget to document and code co-morbidities and complexities that impact your treatment plan. You want to paint that picture through the codes you pick and the narrative documentation. Continue to document co-morbidity and complexities the way you always have and add appropriate codes to support them.

We use the treatment diagnosis for our outpatient claims.   Should we be using the medical diagnosis and then the treatment diagnosis?  Instead of thinking in terms of “medical” and “treatment” diagnosis, in ICD-10 you should think about the primary code, or first listed code, which should support the primary condition you are treating.   Add any additional codes that support the treatment.

How many codes will PT/OT or be recommended or required to report per date of service?

Code the service you are providing.  If you feel that three codes are appropriate, then that would be what you would code.  Be patient specific. There are no “rules” for number of codes in ICD-10, except when you are directed to add an additional code per a note in the ICD-10 manual.

Should we include the co-morbidity ICD-10s in our billing every treatment session or only at the time of evaluation? If the co-morbidity affects the treatment of the patient, then include it every time you bill.

What happens to the V57.1 code? This will be replaced by the most appropriate ICD-10 code. The primary condition will be the one that is coded. If the primary condition is an aftercare code, then a “Z” code will replace the ICD-9 V57._ codes.

Will ICD-10 apply to inpatient PT/OT?  Yes. On October 1, 2015, the use of ICD-10 will begin for all Medicare and commercial patient types, including acute hospital inpatients, and patients in Skilled Nursing Facilities (SNF), Inpatient Rehab (IRF), Long Term Acute Care Hospitals (LTACH) and Home Health (HH)!    Inpatients will have to code more codes; they will use the ICD-10- CM AND PCS codes.

In LE conditions, difficulty walking is a common rehab diagnosis. In UE conditions, pain in whatever region we are treating is typically used. What would be another option for a rehab diagnosis in UE conditions? Use the primary diagnosis. For example, rotator cuff tear. If there is another condition, like lack of coordination or muscle weakness, you can use those. Do not use pain if it is inherent in the primary diagnosis unless the pain is very significant and the primary focus of your session.

When coding medical and treatment diagnosis, should the treatment diagnosis be coded as the primary diagnosis with any remaining treatment diagnosis and medical diagnosis as secondary diagnosis? You would typically code the condition for your treatment as the primary diagnosis. Each clinic should review their systems to make sure that what everyone expects to be on the claim is actually on the claim.  

Does the physician diagnosis code need to be coded by therapists as a “secondary treatment diagnosis descriptor”? Use the specific codes that relate to the treatment you are providing, use the medical diagnosis for medical necessity. Make sure the code you are using supports the treatment you are providing and billing for.

Would weakness be included as rotator cuff tear? If pain is assumed, then why would weakness not be assumed by ICD-10?  We should not code off of assumptions.  Pain, stiffness and generic “symptoms” are typically the conditions that are included in diagnoses that do not need to be added, unless they are so significant that they become the focus of your treatment. Add other codes to support the conditions you are treating.  

How we identify the type of fracture if the MD has not coded it?  Type I vs II, etc.?  Therapists should remember that they are required to code to the highest specificity for the information that they have available to them.  ICD-10 does not require therapists to look into and find a more specific diagnosis if the MD does not provide that information. So, in the example of the periprosthetic humerus shaft fracture, if a therapist is not sure that this was the type of fracture, but was sure that the fracture was in the shaft of the humerus, just code the humerus shaft fracture.  Keep it simple-don’t go looking everywhere; default to the code that supports the highest specificity of the information that you have available.   So, if you are not sure if the fracture is healing or not, or if it is a malunion, you can only code what you do know for sure. The narrative documentation will support the code that you choose.

How do I use CMS tools to find an ICD-10 code?

  • Step 4:  From list of downloaded files, open “Index.pdf” and “Tabular.pdf”
  • Step 5: Search the Index for the patient’s condition.  For example, for a rotator cuff tear, search “Tear”, then go to “Rotator Cuff” with detail to find “Rotator Cuff (incomplete) M75.11
  • Step 6: Go to the Tabular List and use the code from the Index to find the appropriate Chapter.  For example, M75.11 is in Chapter 13, Musculoskeletal. Find the code (e.g., M75.11) and then look for laterality and because this is the left shoulder, choose M75.112
  • Step 7:  If the Tabular List states that a 7th digit is required for the code you are using, add the 7th digit per the description in the Tabular List.

Note that if you already have the Index and Tabular List downloaded and available, you can skip steps 1-4.