One of the most talked about—and most feared—characteristics of ICD-10 is the massive size of the new code set. Whereas ICD-9 contains approximately 13,000 diagnosis codes, ICD-10 has around 68,000—an increase of more than fivefold. With so many codes to choose from, how can you be sure you’re selecting the right one—or even looking in the right place? Well, two of the main reasons patients seek physical therapy are injury and/or pain. So, let’s start there. Here are a few pointers for coding pain and injuries in ICD-10:
Coding for Pain
You’ve probably heard the old real estate cliché, “Location is everything!” But that golden drop of wisdom doesn’t just apply to zip codes and cross streets. For physical therapists, location is probably the most important factor to consider when selecting the ICD-10 code that best describes a patient’s pain. Why? Because when it comes to coding for anatomical site, specificity is key. So, you can wave goodbye to any vague, catch-all ICD-9 codes you’ve grown accustomed to using: as the title of this article warns, “Pain in limb 729.5 doesn’t cut it in ICD-10.” The author of the article goes on to explain that ICD-10 offers “more than 30 code choices” that fall under the pain-in-limb umbrella. Those codes account for not only a variety of specific regions (e.g., upper arm, thigh, and lower leg), but also distinct lateralities (e.g., left and right). In fact, as this CMS page points out, more than a third of the expansion from ICD-9 is due to the addition of separate codes for laterality (e.g., left, right, or bilateral).
Okay, so once you’ve identified the exact location of a patient’s pain, how should you go about finding the appropriate code? According to this article, you’ll find pain codes in three different places within the full tabular list: the body system chapters, the signs and symptoms chapter, and category G89 (Pain, not elsewhere classified) in the nervous system chapter. However, the majority of PT-applicable pain codes appear in chapter 13—a.k.a. the musculoskeletal or “M” code chapter. Examples of common musculoskeletal pain codes include M54.5 (Low back pain), M25.512/M25.511 (Pain in left shoulder/Pain in right shoulder), and M25.551/M25.552 (Pain in right hip/Pain in left hip).
Here’s the kicker, though: if you know what is causing the pain, you should code for the underlying condition instead—although in some cases, it might be appropriate to submit both codes. As this article points out, “The ICD-10-CM guidelines state that if the cause of the pain is known, you should assign a code for the underlying diagnosis, not the pain code. However, if the purpose of the encounter is to manage the pain rather than the underlying condition, then you should assign a pain code and sequence it first.” For a detailed example of this type of scenario, check out this page.
Coding for Injury
Although ICD-10 offers much greater specificity—and consequently, a much larger library of codes—for coding injuries, many of the injury coding guidelines that exist for ICD-9 also apply to ICD-10. But there are a few important differences, including the addition of seventh character extensions, which I’ll explain below.
You will find injury codes in chapter 19 of the tabular list. As you search for the code that best—and most specifically—represents a patient’s injury, you should consider the following factors, as noted here:
1. Episode of care.
This is where the seventh character comes in. If a particular code requires that you attach a seventh character, you will see instructions to do so within the tabular list. As this article explains, there are three different options:
- A – Initial encounter: This means the patient is receiving active treatment for the injury (e.g., surgery, emergency room treatment, or evaluation and treatment by a new medical professional).
- D – Subsequent encounter: This indicates that the patient is receiving routine care for the injury during the healing or recovery phase (e.g., cast removal, medication adjustment, or aftercare and follow-up). Please note that you should not use aftercare codes (e.g., the “Z” codes) for injury aftercare. Instead, you should attach the seventh character “D” to the applicable acute injury code. According to the article linked above: “This change [from ICD-9] will be significant for those post-acute settings that provide subsequent care for injuries.”
- S – Sequela: This indicates that the injury has caused another condition for which the patient is seeking treatment. As the above-cited article explains, this character applies to “complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn. When using extension S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The S is added only to the injury code, not the sequela code.”
2. Injury site.
Within chapter 19, injuries are organized by anatomical site instead of category, which makes it much easier to select the most specific site possible.
Whenever possible, you should account for the cause of the injury (e.g., sports, motor vehicle accident, or slip and fall) and/or the activities leading up to the injury by submitting applicable external cause codes along with the injury code. We’ll talk more about external cause codes in a blog post later this month, but for now, just know that you will find them in chapter 20.
4. Place of occurrence.
Again, if you know where the injury occurred (e.g., gym, athletic field, or swimming pool), you should code for it using an appropriate place of occurrence code. You will also find these codes in chapter 20.
So, to bring it all together, here’s the coding example presented on this CMS page:
Description of injury: Left knee strain that occurred on a private recreational playground when a child jumped off of a trampoline and landed incorrectly.
- Injury code: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter
- External cause code: W09.8XXA, Fall on or from other playground equipment, initial encounter
- Place of occurrence code: Y92.838, Other recreation area as the place of occurrence of the external cause
- Activity code: Y93.44, Activities involving rhythmic movement, trampoline jumping
For a more in-depth look at the logic behind the structure of ICD-10 codes, check out this blog post. Still have questions? Leave them in the comments section below, and we’ll do our best to get you the answers.