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 specificity to a diagnosis, particularly with regard to the episode of care, and as the name implies, the seventh character should always be the seventh digit of a code. As this blog post details, there are three seventh characters related to the episode of care:

• A (initial encounter) describes the entire period in which a patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause.
• D (subsequent encounter) describes any encounter after the active phase of treatment, when the patient is receiving routine care for the injury during the period of healing or recovery.
• S (sequela) indicates a complication or condition that arises as a direct result of an injury.

How do I know when to use the seventh character?

This is huge: You do not always need to attach a seventh character to your diagnosis code. Seventh characters are required for codes in certain ICD-10-CM categories—primarily Chapter 19 (Injury, poisoning and certain other consequences of external causes) and Chapter 15 (Pregnancy, childbirth and the puerperium). You’ll know when to use it because there will be instructions specifying seventh character use within any code book or tabular list you reference. Don’t see instructions? Then “leave the seventh position blank,” explains this blog post. “Adding a seventh character to a code that does not require one will make the entire code invalid.”

What’s the difference between initial (A) and subsequent (D)?

We've seen multiple interpretations of what distinguishes an "initial encounter" from a "subsequent encounter." Based on everything we’ve reviewed, this is the best answer we’ve found: "The 7th character for 'initial encounter' is not limited solely to the very first encounter for a new condition. This 7th character can be used for multiple encounters as long as the patient continues to receive active treatment for the condition." This resource goes on to say: "The key to assignment of the 7th character for initial encounter is whether the patient is still receiving active treatment for that condition."

So, it appears that the words "initial" and "subsequent" have less to do with how many practitioners the patient has already seen or how many visits the patient has logged at your office, and more to do with the patient's treatment phase (i.e., "A" for active treatment and "D" for recovery/healing). That would mean the "A" designation wouldn't be limited to the patient's first visit, even though the label "initial encounter" makes it seem like a one-time descriptor.

What about sequela (S)?

Here’s the deal: the various seventh character options do not necessarily follow a set progression. If the patient is in the active phase of treatment, use A. If he or she is in the recovery phase of treatment, use D. So, when do you use this tricky sequela character? According to Code It Right Online, “‘sequela’ in ICD-10-CM, is a chronic or residual condition that is a complication of an acute condition that occurs after the acute phase of a disease, illness or injury. It can also be caused indirectly by the treatment for the disease or condition.” There’s no time limit on when you can use sequela; “the residual condition may come directly after the disease or condition, or years later.” As explained in this post, “An example of a sequela is a scar resulting from a burn.”

For further insight on sequelae, check out this example from the AAPC: “A patient suffers a low back injury that heals on its own. The patient isn’t seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury. Such a visit may be reported as G89.21 Chronic pain due to trauma and S39.002S Unspecified injury of muscle, fascia and tendon of lower back, sequela.” One caveat to this example: Don’t fall back on an unspecified code. Instead, ask the patient as many questions as possible to get to the root cause of the original injury.

How do I format a code that requires a seventh character?

As this post explains, “If you add a seventh character to a code with fewer than six characters, you must fill each empty slot with a placeholder ‘X.’” For example:

1. You choose S44.11, Injury of median nerve at upper arm level, right arm, for your patient.
2. You look at the instructions for the S44 code category and determine that you must add a seventh character to this code.
3. Because the patient is receiving routine care for the injury in the healing and recovery phase, you determine that D is the appropriate seventh character.
4. S44.11 is only five characters long, so you add an X in the sixth position.
5. You then add your seventh character of D, making the final diagnosis code: S44.11XD, Injury of median nerve at upper arm level, right arm, subsequent encounter.

Do I need to change the seventh character every time a patient returns for another visit?

No, you would only change the seventh character if the patient progressed to a different phase of treatment (i.e., the patient moved from the active treatment phase to the recovery/healing phase).

External Cause Codes

Do I have to use external cause codes?

As explained in this blog post, there's no national requirement mandating any provider—PTs included—to submit external cause codes. However, providers are encouraged to do so when possible. Most of the PT-relevant codes that allow for external cause codes are located in Chapter 19 of the tabular list (which you can access here). Furthermore, some state and regional payers may require the use of external cause codes, so check with each one individually.

What are external cause codes? And how do I use them?

Found in Chapter 20, external cause codes help give context to a particular diagnosis code, and contrary to the name, external cause codes can indicate more than cause. To appropriately apply accurate external cause codes, you'll also have to consider the place of occurrence, activity, etc. We recommend asking yourself the following questions regarding the patient's injury:

1. How did the injury or condition happen?
2. Where did it happen?
3. What was the patient doing when it happened?
4. Was it intentional or unintentional?

When do I use external cause codes?

If it’s possible to submit external cause codes for a particular category or section of codes, you will see instructions to do so within the tabular list. Also, bear in mind that you can never submit an external cause code by itself; it always must have a corresponding principal diagnosis code. Here's a quick clip to show you how to use external cause codes.

What if I don’t know what caused a patient’s injury or condition?

External cause codes are not mandatory (at least not nationally), and remember that you cannot code for what you don't know. So, if you don't know the details necessary to select external cause codes—like what caused the onset of the injury, the activity the patient was engaged in at the time of the injury, or where the patient was when the injury occurred—then don't submit any such codes.

The Great Switch

Should I start using ICD-10 codes now?

No. Payers will deny claims that contain ICD-10 codes prior to October 1, just like they’ll deny claims that contain ICD-9 codes after September 30.

What do I do about patients with visits spanning the transition date?

We’ve written an entire blog post on what to do prior to September 30 and after October 1, including specific to-dos for that 48-hour transition window. You can check it out here.

Do I need to do a progress note, evaluation, or re-evaluation to switch to ICD-10 codes?

No, you do not. Instead, when it comes time to add ICD-10 codes for the patients who previously had ICD-9, you'll simply update the diagnoses in the patients’ charts as they come in for appointments on or after October 1.

Will I need to mass-update my patient notes come October 1?

No, there’s no need for a sweeping code change for all your patient notes. You’ll simply update codes within patients’ charts as they come in for their visits. Or, if you are a WebPT Member, you can use the ICD-9 to ICD-10 Conversion Report to begin saving ICD-10 codes to current patient cases. Then, once October 1 hits, our system will automatically start sending ICD-10 codes—rather than ICD-9—through to your finalized notes.

What about the ICD-10 grace period?

There’s a lot of confusion regarding CMS’s “grace period.”According to CMS, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”

So, what does that mean? It means ICD-10 is absolutely happening on October 1. You'll still receive denials from your commercial payers if you code inaccurately. And, for Medicare claims, you still have to code using valid codes from the accurate code family. For all of the details on what this grace period means for providers, check out this blog post.

Want all this ICD-10 goodness—and more—in a downloadable doc? You’re in luck. Snag your free copy of the One ICD-10 FAQ to Rule Them All: The Definitive Resource for Physical Therapists here.

The Resources

Where can I get an ICD-10 code book?

While you can access the entire code set free of charge here, you may find a PT-specific ICD-10 code book useful for educational purposes, as it likely will provide guidance around coding strategy and processes. We actually sell one in the WebPT Marketplace, so if you're a Member, you can purchase it at a discounted price here. Otherwise, you can purchase it here.

Where can I find the tabular list?

You can download the tabular list here.

Is there an ICD-10 cheat sheet for physical therapists?

We have a wealth of educational resources that you can download here. However, we wouldn’t recommend using a cheat sheet, specifically. As most providers know, certain CPT codes are only payable when used in conjunction with certain ICD-9 codes. Thus, you may be tempted to quickly crosswalk those ICD-9 codes and tack up a new reimbursement cheat sheet—or worse, download the first cheat sheet you find online. Don’t. The rules aren’t the same, and crosswalks typically yield unspecified ICD-10 equivalents. As this ICD-10 for PT article explains, “...one of the main battle cries of the new code set is increased specificity, and the transition to ICD-10 represents a giant step away from the use of unspecified codes (unless one of those codes truly represents the most accurate description of a patient’s condition). Thus, if you submit an unspecified code when a more specific code is, in fact, available, you could put yourself at risk for claim denial.”

Do you have any ICD-10 information specific to hand therapy?

We recommend checking out this ASHT page.

Do you have any ICD-10 information specific to pelvic health?

While we weren't able to address women's health during the webinar, you might find this resource helpful.

Claims, Claims, Claims

Can I dual code in WebPT?

Until October 1, only ICD-9 codes can appear on claims submitted for reimbursement. Otherwise, claims could be denied. Thus, we won't allow ICD-10 codes to appear on finalized notes for non-test patients until the transition takes effect. That said, you can begin using our Conversion Report to save ICD-10 codes to patient charts for those patients who likely will span the transition. Then, after October 1, our system will automatically start adding the ICD-10 codes—rather than the ICD-9 codes—to any finalized notes.

Furthermore, once October 1 hits, we will allow for dual coding in cases involving non-HIPAA covered insurances, as the diagnosis code set will be tied to the insurance. So, if a particular insurance requires ICD-9, you'll be able to add ICD-9 codes for patients who have that insurance.

How do I handle billing for services provided before and after October 1?

We recommend that practitioners finalize notes and get claims submitted for all dates of service prior to September 30 before October 1 hits. That way, you’re able to start with as clean of a slate as possible come October 1. For additional info on dual coding, check out this post.

How many ICD-10 codes are allowed on a claim? And how should I order them?

CMS 1500 forms were updated in 2013 to accommodate ICD-10, so you shouldn't have any problems there. You can list up to 12 ICD-10 codes. Keep in mind, though, that only the first four can be linked to CPT codes. Thus, it’s imperative that you arrange the ICD-10 codes in order of importance, meaning that you should list the codes most relevant to the services provided first.

Are the 1500 forms going to change? How many ICD-10 codes will be allowed on the 1500 form?

The HCFA form has already been updated for ICD-10. While you can include up to 12 codes, you can only list four diagnosis pointers per line (same as now). So for billing purposes, you'll only use your top four codes. That means it's crucial you order your codes according to significance, with the codes that best justify the medical necessity of your services appearing at the top.

How will ICD-10 affect CPT codes (e.g., 97001, 97110, and 97140)?

ICD-10 does have a set of procedure codes, but anyone who currently uses CPT codes to designate procedures will continue to do so. So, if you're using CPT codes, ICD-10 will not change that. You can continue using CPT codes as you do now, even after October 1.

Compliance

How does ICD-10 work with therapy cap exception codes?

There haven't been therapy cap exceptions for a while now. In 2014, Medicare introduced a two-tier exceptions process. In the first tier, which is the Automatic Exceptions tier, therapists affix the KX modifier to necessary services provided above the cap amount. To learn more about the therapy cap, check out this guide.

How does ICD-10 affect the KX modifier?

It doesn’t. You will continue using the KX modifier to denote automatic exceptions in the same way you currently use this modifier.

Will ICD-10 affect G-codes?

ICD-10 will not affect functional limitation reporting (a.k.a. G-code reporting). The current rules will still apply after October 1.

WebPT-Specific

Where in WebPT can I search for and add ICD-10 codes?

You can find the ICD-10 diagnosis code search in the Quick Add, Add Patient, Patient Record, the Subjective section of evaluative notes, and within Daily notes.

How and when will I actually add ICD-10 codes to existing cases within WebPT that contain ICD-9 codes?

You can use our ICD-9 to ICD-10 Conversion Report to begin saving ICD-10 codes to patient cases now. Then, once October 1 hits, our system will automatically start recording ICD-10 codes—rather than ICD-9—on any finalized documentation. If you need to add additional codes to these cases as the patients come in for their visits after October 1, there will be no need to start a new case, or to complete a progress note or re-evaluation; you'll simply update the diagnosis codes in the patient's chart.  

Will WebPT automatically add ICD-10 codes for all existing patients on October 1?

If you've used the Conversion Report to save ICD-10 codes to current patient cases, our system will automatically send those ICD-10 codes through to any notes finalized after the transition. However, you must actually select the appropriate conversion using the report; WebPT will not automatically convert the ICD-9 codes for you. That's because clinical judgment is such a crucial part of the code selection process.

Documentation

How do I handle direct access patients in ICD-10?

We’ve received tons of questions about how to choose the most accurate diagnosis codes for non-referral patients. For advice at every stage of the entire code selection process, check out this blog post.

Keep in mind, though, that this advice isn’t purely for direct access patients. Just because you receive a diagnosis code from a referring provider doesn’t mean you can accept that code blindly, plug it into your documentation and your claim forms, and expect to get paid. Use the physician diagnosis to inform you on the patient’s situation, sure; but then use your own clinical judgment and skills as a medical professional to diagnose the patient based on what you’re actually going to treat. To learn more about selecting diagnosis codes that help justify treatment, check out this blog post.

What’s the difference between medical diagnosis and treatment diagnosis?

The treatment diagnosis is the one that represents the injury or condition that you, as the therapist, are treating. It also is the one that flows over to your billing (if you use WebPT). The medical diagnosis is typically the one that comes with a referral patient's script. It may differ from the treatment diagnosis. If the treatment and medical diagnoses do not match, it's a good idea to get the physician to sign off on the treatment diagnosis before you bill.

Are there V codes in ICD-10?

ICD-9's V codes will become Z codes in ICD-10, but as explained in this blog post, "A simple mapping of the V57 series of codes found in ICD-9-CM over to ICD-10-CM is not possible, as codes that duplicate the V57 series currently are not included in ICD-10-CM classification." Furthermore, because V57.1 does not provide specific, detailed information about the patient's diagnosis—and thus, does not justify the medical necessity of the treatment—using a similar code in ICD-10 could lead to claim denials. Instead, you should select whatever code explains the patient's diagnosis in the most specific way possible.

How do I code for surgical aftercare?

The aftercare Z codes should not be used for aftercare of injuries/fractures where seventh characters are provided to identify subsequent care. That said, you won't always be providing aftercare for injuries—especially in cases involving surgical aftercare. For that reason, ICD-10 contains a few options for coding for surgical aftercare. A couple examples: Z51.89, Encounter for other specified aftercare, and Z47.1, Aftercare following joint replacement surgery. Please note that when you use aftercare codes, you also should code for any underlying conditions/effects. Codes for bone, muscle, and joint conditions that are chronic or recurrent—or that result from a healed injury—are typically found in chapter 13. Also, if you're coding for joint replacement aftercare, you should include a code indicating which joint was replaced (e.g., V43.65, Joint replaced, knee).

What if I don’t have enough information to select a more specific code?

Select the most specific code you can based on the information you have. In some cases, you may need to contact a referring provider for additional information. But if you’ve exhausted all options and still can’t obtain the information necessary to select a more specific code, just make sure you clearly document the reasons behind your code selection within your documentation.

What if a more specific ICD-10 code does not exist?

ICD-10 requires you to code as specifically as possible, but there may be instances in which codes for your specific diagnosis do not exist, and you'll have to use an unspecified or generalized code. You can't code for what you don't know; just make sure you communicate all the details in your documentation. To learn more about when to use unspecified codes, check out this blog post.

Do I remove codes as my patient improves?

If the patient's primary diagnosis changes, and you need to update the plan of care, then you should update the diagnosis code. However, if the patient is simply making progress, you can document his or her progress as normal.

How many ICD-10 codes do I have to add for each patient?

There is no minimum or maximum of the number of codes you can record (though not all will necessarily flow through to your billing, and obviously, you will need to enter at least one). Just make sure you order the diagnosis codes you do submit in order of importance, with the primary diagnosis at the top.

Can’t I just use the ICD-10 code I receive from the referring physician?

Because clinical judgment is such a crucial part of selecting the appropriate diagnosis code, the therapist may need to get involved with code selection to ensure that:

1. The selected code is the most specific one available to describe the patient's condition, and
2. The code justifies the medical necessity of the services provided.

In some cases, the codes sent by referring physicians may meet that criteria, but ultimately, it's your clinic's responsibility to code correctly. After all, it’s your clinic—not the physician’s—that will end up suffering the consequences for inaccurate coding. Don’t just take the physician’s word as gospel. Your physicians don’t have the depth of neuromuscular knowledge and expertise that you do. You are best equipped to make the most specific diagnosis possible, and that is exactly what ICD-10 requires.  

How do I code for multiple body parts?

For single conditions involving multiple sites, such as osteoarthritis, there often is a “multiple sites” code available. If no “multiple sites” code is available, you should report multiple codes to indicate all of the different sites involved. For a patient seeking treatment for multiple conditions involving multiple body parts, you would create separate cases just as you do with ICD-9.

If a patient is experiencing the same condition on both sides (i.e., right and left), how do I code for that? I noticed some ICD-10 codes don’t have “bilateral” options.

In some categories and families of codes, there is no "bilateral" option for denoting laterality. In those cases, you would need to submit separate codes for both the left and the right sides. This is for data-tracking purposes (e.g., tracking the total number of "left" and total number of "right").

If a patient has multiple diagnosis codes, which one should be the primary diagnosis?

Your primary diagnosis code should be the one that most closely aligns with the reason the patient is seeking your services. From there, you should order the codes according to importance and significance regarding medical necessity.

Will we still be able to designate a patient’s diagnosis as “unknown” when first entering the patient into WebPT?

You—or your front office staff—will still be able to enter a placeholder code like you do with ICD-9. Just make sure you to code to the highest level of specificity before you bill. If you use WebPT, we'll ensure you build out each code to its highest possible level of specificity before you finalize the note. If you fail to do that, you'll see an alert.

Any last advice on proper ICD-10 coding?

You’ll find these blog posts on proper code selection useful as you consider all of the various factors you need to code for:

• https://www.webpt.com/blog/how-select-right-icd-10-code-pizza-ordering-speed
• https://www.webpt.com/blog/pt-primer-coding-pain-and-injuries-icd-10
• https://www.webpt.com/blog/medical-necessity-and-icd-10-what-physical-therapists-need-to-know

Also, keep in mind that you cannot code for what you don't know.

Don’t see the answer to your burning ICD-10 question? No worries. Ask it in the comments below, and we’ll get you an answer lickity split.