In order to successfully transition to ICD-10, healthcare providers will need to change more than the actual codes they use; they’ll also have to change the way they think about coding. Because in addition to choosing the right code from a list of 68,000 possibilities, providers must ensure that the code they choose most accurately reflects the specific condition they’re treating so it supports the medical necessity of their services.
As this article points out, “Medical necessity can be a big problem in the physical therapy department”—and that’s because often, the condition that the physical therapist treats is different from the one the referring physician treated. Therefore, the ICD-10 code the physician uses may not validate the medical necessity of the physical therapist’s services. Now, there are plenty of reasonable explanations for why a PT treats a different issue than the physician. Perhaps, for example, the patient is seeking therapy for a condition occurring as a result of the original injury or condition. But with ICD-10, it’s crucial that the therapist use a diagnosis code that accurately reflects this distinction.
So what’s a PT to do? Well, for starters, don’t copy whatever ICD-10 code the referring physician sends over with a patient because that could lead you straight to a reimbursement denial. Instead, apply the code that most accurately describes the diagnosis you’re actually treating. The above-referenced article provides this as further clarification: “A patient suffers a stroke and is attending physical therapy. A lot of patients suffer strokes and don’t need physical therapy. The therapy is actually treating the residual effects of the stroke, so that’s what should be reported as the diagnosis on the claim form.”
Also, try to avoid “generalized” or “unspecified” codes. Even if using certain known CPT and diagnosis code pairs worked well for you in the past, this won’t fly come ICD-10 (unless a general code truly supplies the best representation of your patient’s condition). Instead, always use the most correct (i.e., most specific) code available to you. Not only will you be using ICD-10 as it was intended, you also will be helping to ensure your payers actually reimburse you for your services.
If for some reason you do receive a reimbursement denial, be sure to investigate why. The same article urges providers to research whether the denial resulted from “a lack of medical necessity or a lack of documentation.” Knowing the answer will help you to appeal the denial—if justified—and hopefully avoid receiving additional denials in the future.
Does your clinic have a plan in place for coding for medical necessity with ICD-10? Have you established any quality-check measures? Share your thoughts in the comments section below.