Q and A From ICD-10 Coding Webinar

Physical Therapy Coding Q and A
July 6, 2015
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Sessions 1 – 3 / June 2015

The following is a list of the questions submitted by ICD-10 Coding for Physical and Occupational Therapy webinar participants with answers.

Can we begin billing ICD-10 codes now?
You cannot file claims with ICD-10 codes before October 1, 2015. Some carriers will accept dual coding - so you need to check to see what each carrier will allow. However, only ICD-9 codes will support billing through September 2015. You can practice dual coding now though. Your group will let you know if they want you to start dual coding.

We get paid from CPT codes, not ICD-10 codes; why do we need to report so many ICD-10 codes?
ICD-10 codes support the CPT codes, sometimes the claim can be rejected if the codes do not match.

We get scripts from MDs with no codes. What if the MD put “unspecified” and we see that this is left on the claim coding?
With ICD-10 coding, there should be no unspecified codes on the claim. If you are treating the patient, the primary code should reflect what you are treating. So, even if the physician sends an unspecified code, you should find and use a code that provides specifics on what you are treating. You should have a check and balance system in your clinic so that, if the clinician misses a code and leaves an unspecified code, someone else (e.g., in the billing office) sees that there is an unspecified code and works to get it changed before it goes on the claim.

If our workers compensation payers are not switching to ICD-10, will they accept the ICD-10 diagnosis?
This decision will be state specific; check with the workers comp carrier in your state to ask if they will be accepting ICD-10 codes and, if so, ask the date that they will accept them. Find out if your EHR system will be able to discern the appropriate code to bill on each claim based on payer information that has been loaded into your system. Some EHR systems can bill both codes, or either ICD-9 or ICD-10, based on how the insurance information is loaded.

Will ICD-10 codes change between encounters, such as acute to chronic or unspecified to specified?
The codes that are on each claim should support the service you are providing. With that said, if the patient’s condition changes from acute to chronic and the focus of the treatment changes, it might be appropriate to update the code. However, if your plan of care for a particular diagnosis is progressing normally, there will probably not be any reason to change the coding. You should never start with an unspecified code. If you ask yourself “what is the condition that I am treating”, you should be able to answer that question and find a specified code to support your plan of care.

Does the initial encounter indicate first time receiving treatment for a condition and subsequent encounter indicate a second?
Yes, the initial encounter, identified by the 7th digit “A,” demonstrates the first time the patient received care for this condition. It is usually only found on injury codes. So, the “A” will only be used ONE time, by ONE provider. If the patient has seen the physician first, the physician will use the “A” and the therapist will use the “D” for the subsequent encounter. If the patient sees the physical therapist as direct access, check to see if the patient went to the emergency room; if so, the ER would use the “A”; if not, the PT could use the “A”. The 7th digit “A” is only used by one provider the first time the patient is seen!

We have a coder who handles all of our ICD-9 coding, when we switch to ICD-10 coding, will the physical therapist now have to do the coding?
This is a question for your management. Presumably, you will continue to use a certified coder for dx coding, but you should confirm this.

Does the order we list the ICD-10 codes affect payment…most to least relevant?
You always want to list the primary diagnosis code first. Remember, unspecified codes will trigger a denial.

How do we handle coding for Medicaid patients?
Medicaid will transition to ICD-10 coding on October 1, 2015, in the same manner as Medicare and commercial insurance. (The V57.1 code will not be used.) If an aftercare code is appropriate, it will be a “Z” code instead of a “V” code in ICD-10.

If there is not an ICD-10 code for right or left in regards to bilateral conditions, then what do we code?
Typically, no codes support “bilateral” conditions. If you are identifying a bilateral treatment, you would code the left and then the right. Do not choose unspecified. If you are treating both the right and the left, you will end up using two codes.

For outpatient PT, will or has Medicare indicated if they will be preparing a list of codes that would allow treatment to exceed the cap?
We have not heard anything about that yet. We recommend that you continue ensuring that your diagnosis supports the condition you are treating and make sure your documentation supports the medical necessity. Also, continue to use the UX modifier.

Do we need to code comorbidities or do we only need to mention them in the documentation?
You actually need to code comorbidities if they are affecting your treatment. Regardless of the payer, you always want to document to support medical necessity. Definitely do not forget to document and code co-morbidities and complexities that impact your treatment plan. You want to paint that picture through the codes you pick and the narrative documentation. Continue to document co-morbidity and complexities the way you always have and add appropriate codes to support them.

We use the treatment diagnosis for our outpatient claims. Should we be using the medical diagnosis and then the treatment diagnosis?
Instead of thinking in terms of “medical” and “treatment” diagnosis, in ICD-10 you should think about the primary code, or first listed code, which should support the primary condition you are treating. Add any additional codes that support the treatment.

How many codes will PT/OT or be recommended or required to report per date of service given the exclusion #1 & 2 rules; we were always told to use three different codes?
Code the service you are providing. If you feel that three codes are appropriate, then that would be what you would code. Be patient specific. There are no “rules” for number of codes in ICD-10, except when you are directed to add an additional code per a note in the ICD-10 manual.

Should we include the co-morbidity ICD-10s in our billing every treatment session or only at the time of evaluation?
If the co-morbidity affects the treatment of the patient, then include it every time you bill.

What happens to the V57.1 code?
This will be replaced by the most appropriate ICD-10 code. The primary condition will be the one that is coded. If the primary condition is an aftercare code, then a “Z” code will replace the ICD-9 V57._ codes.

Will ICD-10 apply to inpatient PT/OT?
Yes. On October 1, 2015, the use of ICD-10 will begin for all Medicare and commercial patient types, including acute hospital inpatients, and patients in Skilled Nursing Facilities (SNF), Inpatient Rehab (IRF), Long Term Acute Care Hospitals (LTACH) and Home Health (HH)! Inpatients will have to code more codes; they will use the ICD-10- CM AND PCS codes.

You mentioned that Medicare will use the ICD-10 system, but workers comp and auto insurance are not required to use ICD-10. What about the other insurance companies?
All commercial insurance payers will transition to ICD-10 on October 1, 2015.

Do we code every treatment session? Or just the evaluation? Or the evaluation and then only if the patient’s condition changes and the changes impact PT treatment?
Just as in ICD-9, every claim form that is submitted for a patient treatment must have codes that support the treatment. So, yes, there will be ICD-10 codes for every encounter. Typically, during the evaluation, the therapist identifies the codes. If the focus of the treatment session changes, the codes should change. If the plan of care continues, the codes will typically stay the same.

In the acute care setting with outpatients, should the ICD-10 codes be included in the PT documentation or are the hospital coders supposed to code our documentation and submit the codes with the claim? Currently, we have the ICD-9 codes on our eval documentation only and we code. Should we include ICD -10 codes on daily notes and discharges too?
Each organization will need to review the system that they use to ensure that the correct codes are being applied to the claim forms and that the documentation that is written by the therapist supports the codes. If in ICD-9, the coders currently review the documentation and submit the codes, this will probably continue with ICD-10. You will need to communicate if the focus of the treatment session has changed and if additional codes should be reported on the claim for a daily note. It is important to remember that the provider is always responsible for supporting the code with appropriate documenting, whoever chooses the actual ICD-10 code.

For episode of care, what are we to code if the patient sees us through direct access? Is the initial encounter used and do we need to change the code on the second visit?
If the patient sees you without being seen by any other healthcare provider (like the emergency room), and you are the first encounter, then, yes you would code your encounter as an initial encounter and enter the “A” as the seventh digit on your initial evaluation date. Starting on the second visit, that primary code would need a change of the 7th digit to “D” for subsequent visit. This would continue for other treatments.

Outpatient Ortho: In LE conditions, difficulty walking is a common rehab diagnosis. In UE conditions, pain in whatever region we are treating is typically used. What would be another option for a rehab diagnosis in UE conditions?
Use the primary diagnosis. For example, rotator cuff tear. If there is another condition, like lack of coordination or muscle weakness, you can use those. Do not use pain if it is inherent in the primary diagnosis unless the pain is very significant and the primary focus of your session.

The example you gave was the physician uses the diagnosis of osteoarthritis and then instructed us to use “difficulty walking.” Isn't that a symptom of the physician’s diagnosis?
Difficulty walking is the condition that the physical therapist will be treating. It is not necessarily a symptom of osteoarthritis, and everyone who has osteoarthritis doesn’t necessarily have difficulty walking.

Regarding the example you gave for rotator cuff tear (RTC) and what is expected after RTC repair; why is that different from the LE example and not having to code the symptoms, e.g., gait/diff walking?
The important thing to remember is NOT symptoms, but what is the CONDITION you will be treating in your therapy session. Pain is typically a part of a RTC, but not always included in the LE example. Always code for the condition that your treatment will be supporting.

You have mentioned several times that we can change the ICD-10 during our care, if appropriate. Will that cause claim issues with managed care providers and Medicare?
It should not. You can change the codes as necessary.

Does the physician diagnosis code need to be coded by therapists as a "secondary treatment diagnosis descriptor"?
Use the specific codes that relate to the treatment you are providing, use the medical diagnosis for medical necessity. Make sure the code you are using supports the treatment you are providing and billing for.

In the ACL example, we are not supposed to code for the symptoms resulting from the condition, but in the CVA example, we are supposed to code for the symptoms resulting from the condition. Can you clarify this please?
In the example of the torn ACL, the symptoms of pain and stiffness are included in the primary diagnosis as typical conditions that will be treated. In the CVA example, the symptoms are not inherently explicit in the diagnosis. You might be treating weakness, or spasticity affecting coordination, or pain… that’s the difference. You should ask yourself this question: does the diagnosis include the symptoms and condition that I am treating? Make sure the codes you are adding are relevant and support what you are billing.

Do you know of any book that focuses on ICD 10 for PT/OT?
We do not know of any. We recommend that you learn how to use the ICD-10 manual and focus on the sections that support the specific codes that your clinic sees on a regular basis.

Would weakness be included as rotator cuff tear? or do we add weakness...I am not sure what is assumed. If pain is assumed, then why would weakness not be assumed by ICD-10?
We should not code off of assumptions. Pain, stiffness and generic “symptoms” are typically the conditions that are included in diagnoses that do not need to be added, unless they are so significant that they become the focus of your treatment. Add other codes to support the conditions you are treating.