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 information they need to make that happen. So, without further ado, here’s our second volume of common ICD-10 inquiries, organized by topic. Missed volume one? Click here to review it.
Will ICD-10 eliminate the need to provide extensive detail within patient documentation?
Absolutely not. While ICD-10 makes it much easier to communicate detailed diagnostic information via codes, the transition to the new code set actually will make detailed documentation even more important. CMS explains why here: “If complete information is not captured in clinical documentation, the result will be incomplete documentation for coding that then can impact revenues through delays, missed revenues, outcome measures that don’t clearly or accurately reflect the quality and complexity of the care that is being delivered.” Furthermore, if you don’t do your own coding (i.e., your practice has a coder), then it’s even more important that you provide all the details necessary for proper code selection within your documentation.
I run a cash-based clinic, so I don’t need to worry about ICD-10, right?
The only exceptions to the ICD-10 transition mandate are HIPAA non-covered entities. So, the only way a therapist would be exempt from the transition is if his or her practice qualified as a non-covered entity. Remember, if your patients submit invoices to their insurance companies for reimbursement, you’ll need to provide the appropriate diagnosis codes. And as of October 1, those codes must be ICD-10.
The Grace Period
What happens if Medicare rejects my claim because my ICD-10 code isn’t a valid code?
As explained in our first FAQ, even with Medicare’s grace period, providers still must submit a valid ICD-10 code from the correct family of codes. However, in the event that you submit an invalid code—and, as a result, receive a claim rejection—you will “have the opportunity to resubmit the claim with a valid ICD-10 code,” this CMS resource explains.
What is a “valid” code?
Often referred to as a “billable” code, a valid code is one that has been built out to the highest possible level of specificity. In other words, you’ve added as many characters as you can to the code—including a seventh character, if the code requires one. (For more on seventh characters, check out this blog post.) For example, the code M70 (Soft tissue disorders related to use, overuse and pressure) would not be a valid code, because additional specificity is possible. However, the code M70.11 (Bursitis, right hand) would be a valid code, because you cannot add any additional characters to that code to make it any more specific.
What constitutes a family of codes?
In ICD-10, "families" of codes are typically indicated by three-character headings. According to CMS, “Codes within a category are clinically related and provide differences in capturing specific information about the condition.” For example, M70 appears at the top of the family of codes for soft tissue disorders related to use, overuse, and pressure. All of the codes that are listed underneath that heading belong to that family of codes.
Because Medicare won’t reject claims solely for lack of coding specificity, does that mean that the current diagnosis coding specificity requirements set forth by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) will be more flexible in ICD-10? Will I be in compliance with NCD and LCD policy as long as my ICD-10 code is in the correct family of codes?
No. As explained in this CMS document, the grace period announcement “does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10.” That said, the transition won’t affect the expected level of specificity; in other words, you’ll code to the same level of specificity in ICD-10 that you did with ICD-9. There is, however, one very important exception to that statement: laterality. “LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side,” CMS notes.
Does Medicare’s grace period apply to Medicaid?
No. The grace period guidelines only apply to “Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule,” this resource explains, adding that the grace period “does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary.”
Will commercial payers observe a similar period of flexibility following the transition?
The official grace period announcement only applies to claims billed under Medicare Part B. Thus, it’s up to each individual private payer to determine whether it will offer a period of flexibility and to define the parameters of that flexibility.
The Seventh Character
Will WebPT prompt me to add a seventh character when one is required?
WebPT’s code selection tool will display all possible options for each code, including variations for all applicable seventh characters. You will simply select the one that contains the correct seventh character.
Is there any new information on the difference between “A” and “D” with respect to rehab therapy encounters?
This has been such a hot topic of debate that one of the attendees of a recent CMS national provider call brought it up during the Q&A portion of the meeting. Here’s the exact answer the CMS representative provided, as noted in this call transcript: “There is no specific hard set definition of what active treatment is. There are some examples that are given in the official guidelines, such as surgical treatment, emergency department encounter, and that type of situation. So they’re—it’s not an all-exhaustive list. But what I think is probably clearer is that for the subsequent encounters, usually those are where there’s routine healing or a problem with the healing.”
How do I know which seventh character to use for a chronic or recurrent musculoskeletal condition, like those found in chapter 13 (which contains the “M” codes)?
Seventh characters do not apply to the majority of codes listed in chapter 13, with the exception of most pathological fracture codes. Most of the seventh character-eligible codes that rehab therapists will use occur in chapter 19 (a.k.a. the injury chapter).
Coding for Aftercare
I was under the impression that aftercare codes should not be used as primary diagnoses. Is this true in ICD-10?
While you may have been discouraged from using aftercare codes (i.e., “V” codes), as primary diagnosis codes in ICD-9, that is not the case in ICD-10—at least not according to the official ICD-10-CM guidelines for coding and reporting: “Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter,” the guidelines read. Furthermore, regarding R codes such as the one for gait abnormality, the guidelines offer the following explanation: “Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code.” So, as with a lot of ICD-10 guidance, the context of the patient's situation appears to influence the order of the codes.
It doesn’t seem like there are a lot of codes available to represent specific surgeries. Why is that?
While there is not an aftercare code for every single surgery, in many cases, the proper way to designate the phase of treatment (i.e., indicate that the patient is receiving aftercare) is to code for the original acute injury and add the appropriate seventh character (which would be “D”). So, if, for example, the patient who underwent rotator cuff surgery had originally strained his or her right rotator cuff, you would indicate that you are providing aftercare by using the code S46.011D, Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, subsequent encounter.
Using Multiple Codes
Shouldn’t the primary code be a symptom/complaint code (e.g., difficulty walking), because this code reflects the reason the patient came to therapy?
In some cases, your primary treatment diagnosis code can be a symptom code that reflects what you, as the therapist, are treating. For example, let’s say a patient with Parkinson’s comes to you because he or she is having difficulty walking. In this particular case, you could use a code from the gait abnormalities section (the R26 family of codes) as your primary treatment diagnosis because you, as the therapist, are not treating the Parkinson’s. However, if you are actually providing treatment for an underlying condition, you are encouraged to code for it first, if possible, because it better supports the patient's medical need for your services. For a more in-depth discussion of coding for medical necessity, check out this blog post.
How should I order my codes?
You should submit the codes in order of significance with respect to medical necessity. For more details on using multiple diagnosis codes, check out this blog post.
Should I include codes for comorbidities?
You should include as many codes as necessary to explain the complexity of the patient’s condition to the fullest extent possible. Remember, though, that you cannot code for what you cannot diagnose (with respect to your scope of practice). For referral patients, we recommend working with your referring physicians to ensure you’ve accounted for as many pertinent diagnoses as possible—and that you’ve selected the most accurate, specific codes possible to represent those diagnoses.
Will WebPT alert me if I select an invalid code?
Yes. If you select an invalid diagnosis code (e.g., by failing to code to the highest level of specificity), you will see an alert message across the top of every page in the app. Furthermore, WebPT will not allow you to finalize the note until you’ve added a complete, valid (i.e., billable) diagnosis code.
Is there an unknown code for ICD-10?
Yes. As with ICD-9, WebPT will allow you to add a placeholder “unknown” code for ICD-10. To find it, simply search “unknown” in the ICD-10 code selector.
Can I use WebPT’s ICD-10 tool before October 1? How do I do this?
WebPT's ICD-10 search tool is available for use on a test basis until October 1. To search by ICD-10, simply select the test checkbox that appears at the top of the ICD-9 code selection window. If you need additional help accessing and using the ICD-10 code picker, please contact WebPT Support at 866-221-1870 , option 2, or firstname.lastname@example.org.
Can I save ICD-10 codes to patient charts before October 1?
Due to overwhelming demand from our Members, we recently released our ICD-9 to ICD-10 Conversion Report, which identifies active cases containing ICD-9 codes and allows you to convert those codes to ICD-10. You can use this tool both before and after October 1.
Which user types can add ICD-10 codes?
The permissions for adding ICD-10 codes are the same as those for ICD-9. So any users who can add ICD-9 codes also will be able to add ICD-10.
Will WebPT automatically convert ICD-9 codes to ICD-10 on October 1?
After October 1, the system will default to the ICD-10 code saved for each patient (for the "diagnosis" field). However, you will still need to go in and add ICD-10 codes to the patient's "treatment diagnosis" field the first time you open a new note for that patient on or after October 1.
On the Conversion Report, I have patients with multiple diagnosis codes listed. How do I convert multiple codes?
After you convert an ICD-9 code, that code will appear on the report with a strike-out line. You can then continue converting the rest of the codes for that case, using the struck-through code as a visual indicator of progress. When you’re ready to remove converted cases from the list, click “Generate”; the report will update and converted cases will disappear from the list.
A couple of things to note:
- If you click “Generate” to refresh the report before you’ve finished converting all the codes for a particular case, the case will disappear from the list. This is because the report is built to scan existing cases to determine whether those cases have any ICD-10 codes saved to them. Thus, if a case has at least one ICD-10 code saved to it, the report will not include it as part of the list.
- If you click an ICD-9 code to convert it but then decide to cancel the action, the ICD-9 code will still appear with a strike-out line, even though you didn’t actually convert the code. However, if you then click “Generate” to refresh the report—and haven’t converted any additional codes associated with that case—then the case with the unconverted ICD-9 code will still appear in the report, and the ICD-9 code will no longer appear struck out.
Will I need to delete the ICD-9 codes out of my patient’s case information after October 1?
No. With the new insurance setup, our system will be able to determine which set of diagnosis codes need to be transmitted to your billing software if you have a billing integration. As of October 1, you will see all codes (including ICD-9 codes) listed in the patient’s case information for any finalized notes, but WebPT will only transmit the required diagnosis codes to your billing software.
Which insurances are going to default to ICD-10 and which will default to ICD-9?
All HIPAA-covered payers will require ICD-10 on and after October 1, and our system defaults will be set accordingly. The only insurance types that will default to ICD-9 are “Auto/PIP” and “Other.”
Why are my workers’ comp insurances defaulting to ICD-10? I know they are still using ICD-9.
The majority of state workers’ comp insurances are transitioning to ICD-10 on October 1. If your state is not making the transition yet, no worries. Simply edit the insurance profile and deselect the ICD-10 box.
Why is the Conversion Report showing patients/cases that have not been active in a long time (since 2014, 2013, 2012, etc.)?
The Conversion Report is designed to bring up all patients with active cases in WebPT. If you see a patient that is not actively being treated, it means you never discharged that patient. To resolve this, perform a Quick Discharge. This action should be pretty easy to complete using the Conversion Report as a starting point. Simply click on the patient’s name to go directly to his or her chart, where you can complete the discharge.
Will I still be able to add ICD-9 codes within WebPT after October 1?
Yes. You will still be able to add ICD-9 codes for patients with insurances not requiring ICD-10 (e.g., auto insurances). Insurances with “Auto” and “Other” will default to ICD-9. All other insurance types will default to ICD-10. If necessary, you can override that default and change the diagnosis code set for a particular payer within that payer’s insurance settings.
What if a patient has a primary insurance that requires ICD-10 and a secondary insurance that requires ICD-9?
WebPT will allow you to add both ICD-9 and ICD-10 codes to these patient charts. Then, depending on which insurance you’re billing, the appropriate code will be billed.
Considering that the transition goes by date of service, will claims for dates of service on or before September 30 be paid if I submit them with ICD-9 codes after October 1?
Payers theoretically should be equipped to handle claims with pre-October 1 dates of service—and thus, ICD-9 codes—even when those claims are are submitted after October 1. However, we strongly suggest finalizing all notes for dates of service on or before September 30 prior to the transition on October 1. Why? Because there's no way to know for certain that all payers will truly be ready to handle that distinction. So, just be aware that if you submit pre-October 1 claims after October 1, you may experience delays in payment or have to deal with appeals or claim resubmission for those dates.
How does the transition work for those billing inpatient services?
As CMS explains here, “...for inpatient facility reporting, date of service is defined as the date of discharge.” So if, for example, a patient is admitted to the hospital on September 27, but he or she isn’t discharged until October 2, you would use ICD-10 codes on the claim. Conversely, if that patient is discharged on September 30, you would use ICD-9 codes on the claim.
How should I handle claims with dates of service that span the transition?
There are different rules for different settings and claim types. To review the requirements for each, check out this MLN Matters document.
Additional Help Resources
What’s the deal with the ICD-10 Ombudsman?
CMS has named an ICD-10 Ombudsman “to be a one-stop shop for you with questions and concerns and to be your internal advocate inside CMS.” His name is Dr. William Rogers, and he’s a practicing emergency room physician who has been the director of CMS’s Physicians Regulatory Improvement Team since 2002. You can reach him at email@example.com.
Where can I go for specific coding questions?
The American Hospital Association (AHA) provides a portal where you can submit specific clinical coding questions here. If you take advantage of this free resource, keep these guidelines in mind:
- Do not ask the service to code your entire superbill.
- Do not send an entire patient record and ask for proper coding.
- Do not simply ask for the appropriate code for a certain disease or procedure.
- Do not ask about payments, coverage issues, or general equivalence maps (GEMs).
- You must submit supporting medical records documentation with your question.
- You must specify whether the question refers to a specific clinical setting (e.g., skilled nursing facility, home health, or a particular provider type/specialty).
Are there any training courses or webinars I can attend/view?
In addition to WebPT’s free ICD-10 training courses (which you can access here and here), the AHA offers several free webinars here. Additionally, compliance expert Rick Gawenda of Gawenda Seminars provides specialty-specific courses here.
Didn’t find what you were looking for in this FAQ (or our previous one)? Well, put on your reporter hat, grab a pen—er, keyboard—and hit us with your toughest questions in the comment section below. Even if we can’t provide an answer, we’ll do our best to direct you to someone who can.