In healthcare sectors across the globe, ICD-10 is hardly a new concept. But in the US, we’ve been hesitant to adopt the updated system since its inception more than 30 years ago. In just a few short months, though, that’s all going to change. If you’ve been watching the news, reading the WebPT Blog, or talking with your colleagues, you’ve probably gotten the sense that the ICD-10 delay, debates, and—for some—dread are about to come to an end (for real this time). That’s for a good reason. Because just like the Boston song goes, “as I wander on as clear as the sun in the summer sky, it’s more than a feeling,” whether you feel the winds of change or not, the fact is, the transition to ICD-10 is happening October 1, 2015. And as with any change, questions are bound to arise. With that in mind, here are some of our most frequently asked questions:
What is the “X” character?
You might be thinking, “X marks the spot—duh!” While your codes probably don’t have anything to do with hunting for treasure, the “X” character does mark the spot as a placeholder. But, what is this placeholder’s purpose? For some codes, the placeholder saves space for potential additions to that code’s particular subset. For other codes, the “X” character is necessary because the code has fewer than six characters, but requires a seventh character to denote information about the episode of care. Thus, you must insert the “X” character to complete the code. Speaking of the seventh character:
How do I use the 7th character?
There seems to be some confusion surrounding this enigmatic character. Not only is it hard to understand, but as this blog post explains, “…the seventh character represents one of the most significant differences between ICD-9 and ICD-10 because ICD-9 does not provide a mechanism to capture the details that the seventh character provides.” Typically, rehab therapists deal with these three seventh characters:
- A – Initial encounter
This indicates that the patient is in the active treatment phase for his or her condition. Remember, though, that this phase of treatment may extend beyond the patient’s first visit.
- D – Subsequent encounter
This designation is appropriate for any encounter occurring after the active phase of treatment has ended. That means the patient is receiving routine care during the recovery period.
- S – Sequela
This character is appropriate for complications or conditions that arise as a direct result of an injury. One example: a scar that results from a burn.
Here are a few more things you should keep in mind—as adapted from this CMS document:
- The seventh character applies to obstetrics, musculoskeletal disorders, injuries, and external causes.
- You’ll choose the seventh character based on the care the patient received, not on whether the patient is seeing a new—or different—provider.
- If the patient receives active treatment, then the visit is considered an initial encounter (even if a physician has already seen the patient, in some cases).
- As I mentioned earlier, if a seventh character is required, but your code is fewer than seven characters long, you must put the “X” placeholder in all empty character positions. Otherwise, the code is invalid.
- In many situations, the majority of PT visits occur during the healing/recovery phase of treatment, which means you would use the “subsequent encounter” designation.
- The sequela character is not the same as an acute complication (e.g., an infection resulting from injury).
- You must code the type of sequela first (e.g., scar); then, enter the injury code (e.g., burn).
Phew, that’s a lot to remember. The good news is that your EMR should help you code to the greatest level of specificity. And if you’re looking for additional insight into coding for rehab therapy diagnoses, you might consider grabbing a specialized ICD-10 code book.
Are workers’ comp and auto insurance carriers switching to ICD-10?
Because workers’ comp and auto insurance carriers aren’t HIPAA-covered entities, they’re not legally required to transition to ICD-10. However, CMS has stated that “because ICD-9-CM will no longer be maintained after ICD-10-CM/PCS is implemented, it is in non-covered entities’ best interest to use the new coding system.” CMS will work with these entities to encourage them to make the transition. That said, some carriers will use ICD-10 come October 1, and others will continue to use ICD-9. Whatever the case may be, it’s important to check with all of your payers to determine which codes you’ll need to use.
Do I submit an ICD-10 code based off of the date of service?
The answer to this question is a resounding yes! No matter what date you submit your claims, you must use ICD-10 diagnosis codes for all claims with dates of service on and after October 1, 2015. What happens if you’re submitting claims with multiple dates of service? In the event that you do end up submitting a claim containing both ICD-9 and ICD-10 codes, you must split the claim. (Just be sure to ask your payers about their splitting specifications first.)
What if I have a cash-based practice?
Even if you’re cash-based, you’ll still need to prepare for ICD-10. It’s likely that some of your patients will submit their therapy claims directly to their insurance companies for reimbursement. So, you’ll still want to provide accurate, specific codes.
What if I’m not cash-pay, but I accept direct access patients?
Direct access/self-referred patients are coming to you without a physician prescription, which means it’s typically up to you to determine a diagnosis—and code for it. So, while ICD-10 will require you to code diagnoses to a greater level of specificity, the transition won’t change your diagnostic and coding responsibilities.
I hope this clears up some questions you may have had. And remember, even though the transition will require some extra work on your end, it's not without its benefits. Even if you’re feeling prepared, there’s a chance you might find yourself tired and thinking cold, hiding in your music, forgetting the day, and dreaming of a code you used to know. How do you cope? Just begin dreaming (more than a feeling) ’til you see ICD-9 walk away.
Have more questions? Leave ’em in the comments section below, and we’ll do our best to find the answers.