Navigating the Code Book

Finding your way to the correct ICD-10 Code

ICD-10 is coming on October 1, 2015 and we are getting closer to the implementation date. As the saying goes there is only one way to eat an elephant: one bite at a time.

This month's “bite” is an introduction to navigating the ICD-10 manual. Much is made of the number of codes available in ICD-10, but exactly how do you go about choosing the correct code for your patient. Let's explore different avenues for finding the correct ICD-10 code.

General Equivalence Mapping or GEM's, were developed as a cross-walk between ICD-9 and ICD-10. It is one avenue you can use to identify a starting point in the ICD-10 manual. GEM's are not a quick and easy way to avoid learning ICD-10, but they are a tool to provide assistance in finding the correct code. Using GEM's as a starting point is common with software conversion programs, but the only place to confirm the code selection is from the Tabular list.

The Alphabetic Index is the most common method of locating the correct code. Use the index to find the condition treated in either the full ICD-10 manual, or the ChiroCode ICD-10 manual. For example, look up Sciatica in the Alphabetic List (Index). It will point you to M54.3. Wait! Your job isn't complete. Now move to the Chapter 13 of the Tabular List.

The Tabular List provides the remaining rules and details for selecting the appropriate code. Find M54.3 in the tabular list. This is your starting point for selecting the correct code. Read any instructions associated with the code. For this example there is an Excludes1 note.

M54.3 Sciatica


  lesion of sciatic nerve (G57.0)

sciatica due to intervertebral disc disorder (M51.1)

sciatica with lumbago (M54.4)

M54.30 Sciatica, unspecified side

M54.31 Sciatica, right side

M54.32 Sciatica, left side

Review the documentation for the encounter to determine if any of the excludes notes applies to this visit. Does the physicians note identify laterality? If not, M54.30 must be selected. Does the patient also have back pain? If so, see code M54.4 for further instructions.

When learning to code in ICD-10 it will take time to become familiar with the particulars of the codes used most frequently in your office. With practice, patience and perhaps a bit of guidance it will be a manageable transition.

For help with ICD-10 including webinars and other services click here


HIPAA Authorizations

11 Elements in HIPAA Authorizations


Does your office disclose patient information properly?  The following list can be used to determine if the records request meets HIPAA’s requirements for a valid authorization.

 Does the authorization contain:

  • Patient’s name
  • Type of information to be disclosed
  • Name of the provider from whom the information is being requested
  • Name of the recipient of the information
  • Purpose for the disclosure
  • Signature of patient (or legal representative and their relationship)
  • Date of signature
  • Effective date and expiration date or event
  • Statement informing the patient of their right to revoke the authorization
  • Statement that the patient may inspect or copy the information disclosed
  • Statement regarding any fees assessed for providing the copy

This list may not be all-inclusive because individual state laws may require additional elements.

HIPAA also requires that the authorization contain either an expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure.  Examples provided by the Department of Health and Human Services include “one year from the date the Authorization is signed” and “upon the minor’s age of majority”.

An authorization remains in effect until its expiration date, expiration event or until the individual revokes the authorization in writing. 



Responding to Claim Denials - Part 1

Responding to Insurance Denials.

It is frustrating to receive correspondence from an insurance carrier bundling, down coding or denying your claims.  Each day offices open correspondence from the insurance companies only to find that some or all of a patient’s services have not been paid as expected. Some have been placed on hold pending receipt of medical records while others are bundling codes together or just flat denying coverage.

Denials are especially difficult to understand if the insurance company had previously been paying for services.  Some carriers will even pay for subsequent dates, while one or more services are denied pending receipt of the records. What’s the rationale?  What do you need to do?

#1 Check the Details. 

Why was the claim denied?  Codes bundled?  Not a covered service?  No coverage?  Medical Necessity?

Review the claim as you submitted it.  Check for the appropriate number of units.  Some codes can’t have more than one unit:  Electrical Stim (97014/G0283) and Mechanical Traction (97012) are both examples of codes where more than one unit is inappropriate.  Some codes with three or more units may trigger a review for some carriers:  Massage (97124) and Manual Therapy (97140) are examples of codes that may be billed with multiple units but may cause a records request.  These codes will generally be approved when medical necessity is shown and the codes are appropriately documented in the medical records. 

No coverage?  Talk to your patient!  Do you have the right insurance? 

Not a covered service?  Check your verification of benefits!  If it should have been covered, keep going! 

#2 Review the modifiers applied.

If a chiropractic manipulation was performed on the same day as an exam or re-exam, was the modifier 25 applied to the E&M code?  Is the modifier 59 required on one or more of the therapy codes billed?  CPT codes of 97112, 97140 and 97124 may require the use of this modifier.  Some areas of therapy must be outside the area(s) being adjusted. Has the carrier implemented the new –X modifiers?  Before you add the modifier and resubmit, ensure the records support the use of the modifier.

#3 – Is it correctly coded?

Does the diagnosis listed on the claim support the regions of your CMT?  If you are adjusting 3-4 regions and diagnosing only 1 region, it may trigger a denial.   If you are using CPT 97140, are you outside the area(s) being adjusted?  Are you using the correct CPT for electrical stimulation (G0283/97014/97032)?  

#4 - What story does my claim tell? 

Does the Date of Onset (CMS-1500 box 14) contain a “stale” date?  Is it more than 30-60 days old?  Does it reflect the date of your last re-exam?   With Medicare and indemnity plans t is important to update this field as re-exams are performed and treatment plans are updated.  Onset dates that have aged more than 30-60 days can be a review flag for these payers. The necessity of continued care must be established at each re-exam.  These exams should be performed every 30-45 days or 10-15 visits. 

If any of these problems exist on the claim in question, update your software to reflect the corrections and create a corrected claim.  If your software does not flag the claim as a corrected claim, write “CORRECTED CLAIM” on the top of the claim form.

This article addresses coding issues, but what if your coding is correct and your claim is still being denied?  In part two of this series, we'll look at how to manage appeals