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:

WebPT + Billing Software - Regular BannerWebPT + Billing Software - Small Banner

Characters

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.

Dual Coding

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.)

Direct Access

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.

  • ICD-10 FAQs Image

    articleFeb 28, 2015 | 6 min. read

    ICD-10 FAQs

    We recently hosted a webinar focused on helping PTS, OTs, and SLPs prepare for the ICD-10 switch. We got a lot of questions—so many, in fact, that we decided to organize the most common ones into an easy-to-reference blog post. Read on to find the answers to all your burning ICD-10 queries. Don’t see your question? Post it in the comments section below, and we’ll find you an answer. Does ICD-10 affect CPT codes? According to this …

  • The Ultimate ICD-10 FAQ: Part Deux Image

    articleSep 24, 2015 | 16 min. read

    The Ultimate ICD-10 FAQ: Part Deux

    Just when we thought we’d gotten every ICD-10 question under the sun, we got, well, more questions. Like, a lot more. But, we take that as a good sign, because like a scrappy reporter trying to get to the bottom of a big story, our audience of blog readers and webinar attendees aren’t afraid to ask the tough questions—which means they’re serious about preparing themselves for the changes ahead. And we’re equally serious about providing them with …

  • The PT's Guide to Billing Image

    downloadJun 7, 2016

    The PT's Guide to Billing

    When it comes to physical therapy billing, you have to know your stuff—because even the simplest mistakes can cause denials. Of course, knowing billing backwards and forwards doesn’t have to be complicated. That’s why we created a comprehensive billing resource specifically for PTs. Take the guesswork out of billing. Enter your email address below, and we’ll send your free guide.

  • The Ultimate ICD-10 FAQ Image

    articleSep 1, 2015 | 21 min. read

    The Ultimate ICD-10 FAQ

    Yesterday, we hosted the largest webinar in WebPT history . Thousands of rehab therapy professionals attended the live session, which focused on ICD-10 coding examples . As expected, we received a lot of questions. Below is a collection of the webinar’s most frequently asked questions. The Seventh Character Craze What is the seventh character? The seventh character didn’t exist in ICD-9 , so it’s caused a great deal of confusion. Essentially, it’s a mechanism for applying greater …

  • Dual-Coding Wonder Twin Powers: Activate? Image

    articleSep 2, 2015 | 3 min. read

    Dual-Coding Wonder Twin Powers: Activate?

    Thirty days has September—and so has your clinic to prepare for ICD-10. Just one month from now, you’ll have to start using ICD-10 codes on most claims with dates of service on or after October 1, 2015. Did you see I wrote, “most”? That’s not a typo. The reason I can’t say “all” is because not all payers are switching to ICD-10. That means you’ll have to be bi-code-lingual (so don’t purge your brain of all ICD-9 …

  • Costly ICD-10 Traps and How to Avoid Them Image

    articleAug 26, 2015 | 5 min. read

    Costly ICD-10 Traps and How to Avoid Them

    Imagine you’re playing a game . More specifically: an ICD-10 Rube Goldberg-style game . To win, you have to scurry through a series of stages without getting caught in costly traps. But what happens when you find yourself at the mercy of the swiftly-turning plastic crank? Before you know it, the cage has lowered and you’re out of the game —forever separated from your cheddar. Okay, so ICD-10 isn’t a game of zany action on a crazy …

  • ICD-10 FAQ Part Three Image

    articleOct 20, 2015 | 16 min. read

    ICD-10 FAQ Part Three

    In the movie world, threequels have a reputation for failing to match the glory of their predecessors (The Hangover Part III, anyone?). It’s almost like the writers know they’re out of material, but instead of knowing when to fold ’em, they continue to hold ’em—right up until the inevitable flop. But with ICD-10, the questions just keep getting better—which means the third and latest installment of our ICD-10 FAQ is even juicier than the last. So, grab …

  • One ICD-10 FAQ to Rule Them All Image

    downloadNov 25, 2015

    One ICD-10 FAQ to Rule Them All

    The transition to ICD-10 was an unexpected journey for many healthcare providers—and making the switch was no easy quest. That’s why we traveled far over the Misty Mountains cold—and to dungeons deep and caverns old—to gather the answers to your most frequently asked ICD-10 questions.   Now, it’s time to head to the Shire, eat second breakfast, and make your coding concerns disappear. To go there (and back again), download the One ICD-10 FAQ to Rule Them …

  • Medical Necessity and ICD-10: What Physical Therapists Need to Know Image

    articleAug 11, 2015 | 4 min. read

    Medical Necessity and ICD-10: What Physical Therapists Need to Know

    ICD-10 has raised a lot of questions, and with good reason:  it differs greatly from its predecessor, ICD-9 , after all. One critical question is, “How will ICD-10 affect the way in which I diagnose?” Currently, many physical therapists receive diagnosis codes from referring physicians, and they just carry those over into their notes. But ICD-10 isn’t solely about coding patient diagnoses correctly; it’s also about coding the correct patient diagnoses. As Lori Purcell, RHIA, CCS, explains …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.