Healthcare has changed dramatically over the last twenty years. The comfort of going to the doctor and actually being seen with care is no longer of existence. Healthcare has turned into a business. Instead of patient care doctors are now trying to figure out to keep afloat. Government implementation of new rules and regulations makes it difficult for a practice to run efficiently.
On October 1, 2015 after much delay the government made it
mandatory to convert all International Classification of Disease 9 (icd) to ICD
10. United States will be last country to adopt this new classification manly
because our healthcare system: hospitals, insurance company, providers, and etc
are not unified. To become one the
government and private companies stepped in to create a universal platform and
electronic data interchange (EDI). In EDI procedure codes (cpt), patient’s
pertinent information, insurance information, is deciphered and providers get
paid accordingly.
The issue: ICD9 and CPT codes needs to be matched up
according to its specification. For
example,
724.2 (icd 9) is low back pain or Lumbago, 62310 (cpt) is an
epidural injection cervical region; needless to say, a back pain code with a
neck injection will be rejected. The
correct cpt code is 62311 epidural injection lumbar region with icd 9 it’s
pretty clear and concise one icd 9 to one procedural code; back region with
back injection.
Now with icd 10, the same diagnosis code 724.2 now needs to
be broken to its highest level of specificity.
We now have to thoroughly code
correctly, which lumbar facet joint L1-L5, what if it’s in the T12-L1 facet
joint. T12 is considered Thoracic; thoracic icd code belongs with 62310 cpt
code. But, let’s keep it simple. Icd 9 724.2 lumbago conversion to ICD 10
Lumbago NOS
Description Synonyms
- Acute
low back pain < 3 months
- Acute
low back pain for less than 3 months
- Chronic
low back pain
- Chronic
low back pain > 3 months
- Chronic
low back pain for greater than 3 months
- Chronic
low back pain greater than 3 months
- Chronic
low back pain greater than 3 months duration
- Chronic
lumbar pain
- Low
back pain < 6 months
- Low
back pain for less than 6 months
- Low
back pain in pregnancy
- Low
back pain without radiculopathy
- Low
back pain wo radiculopathy
- Low
back pain, mechanical
- Lumbago
- Lumbar
back pain acute,<="" li="" style="box-sizing:
border-box;">
- Mechanical
low back pain
- Pain
of lumbar, acute, for less then 3 months
Type 1 Excludes
- low
back strain (S39.012)
- lumbago
due to intervertebral disc displacement (M51.2-)
- lumbago
with sciatica (M54.4-)
ICD-10-CM M54.5 is
grouped within Diagnostic Related Group(s) (MS-DRG v30.0):
Type 2 Excludes
- arthropathic
psoriasis (L40.5-)
- certain
conditions originating in the perinatal period (P04-P96)
- certain
infectious and parasitic diseases (A00-B99)
- compartment
syndrome (traumatic) (T79.A-)
- complications
of pregnancy, childbirth and the puerperium (O00-O9A)
- congenital
malformations, deformations, and chromosomal abnormalities (Q00-Q99)
- endocrine,
nutritional and metabolic diseases (E00-E88)
- injury,
poisoning and certain other consequences of external causes (S00-T88)
- neoplasms
(C00-D49)
- symptoms,
signs and abnormal clinical and laboratory findings, not elsewhere
classified (R00 -R94)
- M00-M02 Infectious
arthropathies
- M05-M14 Inflammatory
polyarthropathies
- M15-M19 Osteoarthritis
- M20-M25 Other
joint disorders
- M26-M27 Dentofacial
anomalies [including malocclusion] and other disorders of jaw
- M30-M36 Systemic
connective tissue disorders
- M40-M43 Deforming
dorsopathies
- M45-M49 Spondylopathies
- M50-M54 Other
dorsopathies
- M60-M63 Disorders
of muscles
- M65-M67 Disorders
of synovium and tendon
- M70-M79 Other
soft tissue disorders
- M80-M85 Disorders
of bone density and structure
- M86-M90 Other
osteopathies
- M91-M94 Chondropathies
- M95-M95 Other
disorders of the musculoskeletal system and connective tissue
- M96-M96 Intraoperative
and postprocedural complications and disorders of musculoskeletal system,
not elsewhere classified
- M99-M99 Biomechanical
lesions, not elsewhere classified
(Welcome to Hell) We now have to very detailed
and specific with our codes. We also have be aware that we the provider are
following correct local coverage determination of each insurance. Not all insurance accepts all of the icd 9
codes for a cpt code.
Example: CPT 62311 Lumbar ESI, Medicare
acceptable code 724.4 or 721.3 not 724.2.
Aetna acceptable code 724.2 only.
Cigna 721.3 and 724.2
BCBS all depends on which state it is from.
If the biller and coders can’t correctly bill
reimbursement will be delayed. If the provider’s office does bill correctly and
the EDI can’t correctly transpose the alphanumeric to the insurance companies
reimbursement will be delayed. Bottom if the parties does is not up to par with
all the new changes, the person who will most effected would be the
member/patients.
Without proper reimbursements providers will
stop seeing its patents.
Insurance companies will need to hire customer
service overall in the members and providers department to keep up with all the
phone call for complaints.
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