Like the many Land Before Time sequels, the versions of our ICD-10 FAQ keep on-a-comin’. But—unlike those beloved dinosaur tales—I don’t anticipate 12 more versions (plus a TV series) will be necessary to cover what’s to come with ICD-10. Still, the questions continue to roll in—albeit a bit slower than they did a couple of months ago. However, most of the inquiries we’ve received in recent weeks have been super specific. That’s why, our most recent webinar—the ICD-10 Open Forum—included an extended audience Q&A session hosted by Dr. Heidi Jannenga and compliance expert Rick Gawenda. In case you missed it, I’m going to make like Littlefoot and take on some of our most frequently questions from the webinar while chewing on some prehistoric ferns (or something like that):
Where do I find information on state regulations related to ICD-10?
We suggest contacting your payers, as well as consulting your state association’s website/state practice act, to get the most up-to-date, state-specific information.
What’s the difference between R53.1, Weakness, and M62.81, Muscle weakness (generalized)?
According to this resource, M62.81 is typically classified as a disorder characterized by a reduction in the strength of muscles in multiple anatomic sites, or a reduction in the strength of muscles in multiple anatomic sites. R53.1, on the other hand, is a sign or symptom associated with:
- weakness and diminished or absent energy and strength;
- debility, or lack or loss of strength and energy;
- physical weakness, lack of strength and vitality, or a lack of concentration;
- lack of physical or mental strength;
- liability to failure under pressure or stress or strain;
- weakness; and/or
- lack of energy and strength.
If I shouldn’t use unspecified codes, then why are they even an option?
The unspecified codes exist in case there truly is not another, more specific option available. However, if a more specific option is available, you absolutely should use it.
If a patient experiences muscle weakness in a specific area, should I use M62.81?
The clinical description for M62.81 reads, "A disorder characterized by a reduction in the strength of muscles in multiple anatomic sites." Because this code describes weakness in multiple anatomic sites, it would not be appropriate for weakness that exists in a specific location. As mentioned in our other FAQs, if available, you should always code for the underlying condition causing the muscle weakness first.
Can I list a condition like poor balance as a primary diagnosis?
You should code first for the underlying condition (i.e., what's causing the patient's balance issues). If you can’t determine the underlying condition, ICD-10 code R26.81, Unsteadiness on feet, might be a good option.
What code should I use for difficulty walking? R26.2 or R26.89?
Depending on your evaluation, you might discover the reason behind the disordered movement is best described by one code more than the other. Each code has its own synonyms that can help you make your selection.
For example, this resource explains that the description synonyms for R26.2, difficulty walking are:
- Difficulty walking
- Walking disability
The description synonyms for R26.89, Other abnormalities of gait, and mobility are:
- Cautious gait
- Gait disorder due to weakness
- Gait disorder, painful gait
- Gait disorder, weakness
- Gait disorder, postural instability
- Gait disorder, multifactorial
- Toe walking and toe-walking gait
- Limping/limping child
Should I code for accidents/incidents that affected my patients in the past?
You cannot—and should not—code for what you don’t know. If you can’t say for certain that the accident/incident directly correlates to the patient’s current condition, don’t code for it.
What if I have a highly-specific clinical coding question, and I can’t find the answer?
We’re happy to answer your questions to the best of our abilities. However, if the example is extremely clinical in nature, we can’t give you a definitive answer. But, we do know of a resource exactly for these types of situations. If you are able to supply supporting documentation for your particular scenario, you can submit your coding questions via this AHA portal.
How does WebPT protect providers from making ICD-10 coding errors?
WebPT prompts users to select the most complete code possible and does not allow users to bill incomplete codes. However, you’ll still need to use your clinical judgement to make the proper selection from all of the available codes.
Will WebPT allow providers to use ICD-9 codes for patients with dates of service prior to October 1?
Yes. WebPT automatically recognizes whether the patient should have ICD-9 or ICD-10 codes based on the date of service on the note.
ICD-10 isn’t destined for extinction (yet); so, if you still have questions, post them in the comments section below. As soon as we have a break from running with the herd, chompin’ on greens, and making awesome dinosaur-like noises, we’ll do our best to answer them. But don’t worry, we aren’t actually that great at making dinosaur noises, so it won’t take us very long to respond.