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ICD-10 Therapy Diagnosis Selection Phenomenon

Licensed Physical, Occupational and Speech Therapists across all setting types continue to have the same challenge since October 1, 2015: Selecting the “correct” ICD-10 diagnosis code.


When searching the web, many articles and references are available on this topic and yet the same questions keep popping up day after day.


Top 3 Risky Assumptions about ICD-10:

  1. An electronic medical record (EMR) system automatically solves issues related to ICD-10.

  2. ICD-10 rules are static and have been well-established.

  3. ICD-10 codes are not related to billing, so reimbursements and denials are not impacted by what ICD-10 codes are selected.


Let’s simplify what you need to know and how to fill the void once and for all when it comes to properly selecting ICD-10 codes (before ICD-11 codes are implemented!).


Identify the Main Diagnosis: Begin by assessing the patient and their medical history. Understandthe patient's medical condition, symptoms, and the reason for seeking therapy. Determine the primary diagnosis or the main reason for the patient's encounter. Conduct a comprehensive clinical evaluation to determine the nature and severity of the patient's condition. This evaluation includes physical examinations, functional assessments, and any relevant diagnostic tests. Determine the primary diagnosis or the condition that is the primary focus of the therapy treatment. This should be the primary condition that is the focus of the treatment.  Start with the most specific code available. ICD-10 codes are structured hierarchically, with more digits offering greater specificity. Identify the appropriate chapter or section in the ICD-10 codebook that corresponds to the patient's condition.


Learn the Basics:  Familiarize yourself with the structure of ICD-10 codes. Each code consists of three to seven alphanumeric characters. Understand that ICD-10 codes are organized into chapters and sections, which group related conditions together.


Locate the Alphabetic Index: Use the alphabetic index to search for keywords related to the patient's diagnosis. This index will lead you to one or more potential codes.


ABCs

Verify in the Tabular List:  The Tabular List provides additional details and notes for each code. Choose the code that best describes the patient's condition and is the most specific. Avoid using unspecified codes (those ending in "X") unless there isn’t a more specific code available. Some codes require specifying laterality (left or right side) so don’t pick “unspecified” when you know which side you are treating.


Check for Additional Documentation Requirements: Some codes may require additional documentation or specific criteria to be met for proper coding. Pay attention to any instructional notations, guidelines, or code inclusion/exclusion notes. As an example, canalith repositioning for benign paroxysmal positional vertigo (BPPV) is typically only reimbursed when ICD-10 codes H81.11, H81.12, H81.13 are selected. Also, ensure that the selected code aligns with the patient's clinical evaluation and documented medical history.


Use Secondary Codes: In some cases, patients may have multiple conditions that require therapy. You can use secondary diagnosis codes to capture additional relevant conditions.


Pay Attention to Code Extensions: Some ICD-10 codes may have additional characters (extensions) toprovide more details. These extensions can include "A" for an initial encounter, "D" for a subsequent encounter, and "S" for sequela. Use these extensions when applicable.


Check for Code Inclusion and Exclusion Notes: Be aware of any code inclusion or exclusion notes in the Tabular List. These notes can guide you in selecting the appropriate code based on specific conditions or circumstances.


Code Sequencing: Sequence the primary diagnosis code first, followed by any secondary or contributing diagnosis codes, if applicable. The primary diagnosis is the main reason for the encounter.


Apply Z Codes for Health Status and Factors Influencing Health Status: Use Z codes to indicate factors affecting the patient's health status but not representing a current illness or injury. These codes can beused for health maintenance, family history, and other non-disease-related factors, but should not be listed as primary therapy diagnosis codes.


Stay informed about changes and updates to ICD-10 codes, as these codes can be revised and expanded over time. As an example, G20 representing Parkinson’s diagnosis has now been enhanced with five more specific codes to select from (G20.A1, G20.A2, G20.B1, G20.B2, G20.C).


Accurate and specific coding in therapy is essential for billing, insurance claims, and patient care. Ensure that the selected ICD-10 diagnosis codes align with the patient's clinical presentation and support the medical necessity of skilled therapy services. There is no specific number of codes that you are required to select per patient case, but just remember that when you select an ICD-10 code, the documentation needs to include measurable objectives and functional goals for each diagnosis code in order to paint a clear picture of your skilled clinical analysis. If you have doubts or encounter complex cases, seek guidance from your compliance officer.


ICD-10 Codes Most Frequently Selected by Therapists:

M54.50 Low back pain, unspecified

M54.2 Cervicalgia

M25.511 Pain in Right Shoulder

M25.561 Pain in Right Knee

M25.562 Pain in Left Knee

M25.551 Pain in Right Hip

R26.2 Difficulty in waling, not elsewhere classified

R26.81 Unsteadiness on feet

R26.9 Unspecified abnormalities of gait and mobility          

M25.571 Pain in Right Ankle and Joints of the Right Foot

M25.572 Pain in Left Ankle and Joints of the Left Foot

M54.6 Pain in the Thoracic Spine

M54.16 Radiculopathy in Lumbar Region

M54.12 Radiculopathy, Cervical Region

 

ICD-10 Selection Examples:

Let’s use some of our most frequently used codes as examples. R26.2 is defined as “difficulty in walking, not else classified”. This code has a warning (listed as Excludes 1) that says if you select this code, you may not simultaneously include R29.6 Falling or R26.81 Unsteadiness on feet.


M54.5 Low Back pain also has a warning (listed as Excludes 1) that says if you select this code, you may not simultaneously include S39.012 low back strain, M51.2 Lumbago due to intervertebral disc displacement or M54.4 Lumbago with sciatica.


An opposite example would be for M25.5 Pain in joint. This code allows you (listed as Excludes 2) to also attach other joint pain codes because the patient may have multiple restrictions at the same time. So, codes such as pain in the hand and fingers (M79.64) or pain in foot and toes (M79.67) could also be listed simultaneously. 


M25.56 Pain in knee may look like a decent code, but generally you will know which knee presents with pain, so just select M25.561 for the right knee or M25.562 for the left knee (don’t pick M25.569 for the unspecified knee). 


For the official 2024 reference and complete list: https://www.cms.gov/files/zip/2024-code-tables-tabular-and-index-updated-06/29/2023.zip (select the bottom PDF titled “ICD20cm_tabular_2024.xml”)


For the official 2024 addendum updated list: https://www.cms.gov/files/zip/2024-addendum-updated-06/29/2023.zip (select the bottom PDF titled “ICD10cm_tabular_addenda_2024”)

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