The 2015 Work Plan for the Office of the Inspector General (OIG) includes a focus on chiropractic services. This means chiropractors can expect to see more audits and reviews in the coming year because private payers pay attention to the OIG's focus as well.It is more critical than ever to make sure documentation can stand up to scrutiny so proper payment follows.
When ICD-10 kicks in on Oct. 1, you will have to work even harder on your documentation. ICD-10 presents new challenges because the codes are more detailed. However, the majority of this new detail is fairly straightforward. Chiropractors primarily use musculoskeletal codes, and most of these pertain to the spine or the extremities.
For spinal codes, the new detail added to an ICD-9 code will frequently separate the code into eight or nine general equivalents in ICD-10, representing the different regions of the spine. While this means there are more codes to consider, most DCs already specify that kind of detail in their records (i.e., cervical, cervicothoracic or thoracic). You don't need that information for ICD-9 code selection, but it is typically already documented because that is just good practice.
For example, if you record "Degenerative disc disease of the mid-cervical region," the ICD-9 code is 722.4 Degeneration of cervical intervertebral disc. The ICD-10 codes are similar, but there are more choices. The new level of detail specifies the anatomical region.
Using the same notation, you could select M50.32 Other cervical disc degeneration, mid-cervical region. You could get by without making any changes to your documentation, but you will still need to know what the new codes are in order to submit a clean claim.
For extremity codes, the ICD-9 option often moves to three choices in ICD-10: right, left and unspecified. For example, if you state: "right elbow pain", the ICD-9 code is 719.42 Pain in joint; upper arm. The ICD-10 equivalent can be selected without enhancing the documentation at all. You do not have to modify the work you do because the extra detail required by ICD-10 is already found in your notes. The new code is M25.522 Pain in left elbow.
Alternatively, many codes do specify details you may not routinely document. For example, most headache codes include options for headaches which are intractable or not intractable. Intractable means "hard to control or deal with" and is often used in the medical world to describe a condition that does not respond readily to medication.
An ICD-9 record could say "tension headache" and the code might be: 339.10 Tension type headache, unspecified. But in ICD-10, the record might need to specify "Tension-type headache, intractable (i.e., does not respond to medication)" and the code would be G44.201 Tension-type headache, unspecified, intractable. Alternatively, if the record states "Tension-type headache, not intractable (i.e., improves with medication)," the ICD-10 code would be G44.209 Tension-type headache, unspecified, not intractable or tension headache, NOS.
It is important to note that the code for the headache that is not intractable includes the designation NOS, which means "not otherwise specified." Coding guidelines tell us that in the absence of a mention of intractable or not, the NOS code can be selected. However, since the codes now offer this level of detail, doctors should consider documenting this new terminology. It will make code selection easy, and it will also make it easy for a reviewer or auditor to agree with the code chosen.
Upon closer examination, it should be noted that these headache codes are all unspecified. Unspecified codes should be investigated for more detailed options because it is expected that payers may request a specified code before deciding what to do with a claim. The options for episodic or chronic tension headaches were available in ICD-9 and they are still available in ICD-10. However, each one is separated into an "intractable" and "not intractable" option.
Avoiding unspecified codes is always a good idea unless there are no better options. Therefore, a more complete note would include not only the type of headache (in this case tension), but whether or not it is episodic or chronic. And it also would need to include information about whether or not the headache responds to medication (intractable). For example, if the record states "Chronic tension headache that does not respond to over-the-counter medication," the ICD-10 code would be G44.221 Chronic tension-type headache, intractable.
According to auditors and reviewers, chiropractors need to work on documentation improvement. ICD-10 only adds to this challenge, but a simple plan [see app version of this article for more info] can ensure preparedness for the day that reimbursement depends on it.
Dr. Evan Gwilliam graduated as valedictorian from Palmer College of Chiropractic in 2003 and later earned a master's of business administration. He is the only chiropractic physician who is also an AAPC-certified ICD-10 instructor and sits on the editorial board for ICD10Monitor.com. He is also a certified professional coder, medical compliance specialist and certified professional medical auditor; and speaks on compliance and coding topics all over the country as vice president of the ChiroCode Institute. He can be reached at