Watch out for New ICD-10-CM Codes

New ICD-10-CM codes became effective on October 1, 2021 and there are some interesting, new codes that providers need to be aware of. At first glance, just looking at the actual description of the code itself might lead you to choose one over the other, but further examination into the details of why the code was created provides some essential guidance.

Note: Please keep in mind that at the time of publication of this article, revisions to payer policies addressing the October 1, 2021 code changes have been limited. Be sure to watch for payer announcements regarding any preferences or policy updates as a result of these changes.

Low Back Pain Expanded

There has been some interesting movement on this diagnosis over the last several years in large part due to the realization that there is a need to reduce the use of opioids for treating this common condition. Code M54.5 has been expanded into the following — each with their own separate code:

  • Low back pain, unspecified
  • Vertebrogenic low back pain
  • Other low back pain

It MIGHT seem that vertebrogenic would be the right one to use because chiropractic adjustments are for the spine - aka vertebra. A review of the application for code expansion by Michael R Marks, MD MBA (Senior Medical Director of Relievant Medsystems), reveals that this was intended or requested specifically to report a certain condition in which the vertebral endplate is damaged and diagnosed using “objective MRI findings of Modic changes and endplate defects.” Based on this information and a review of other literature about this condition, the codes for “other” or “unspecified” would be more appropriate for chiropractic or physical therapy care. Since the sub-terms “Loin pain” and “Lumbago NOS” have been added to the “unspecified”, that would be the most likely replacement option instead of “other.” Remember that when using “other” for any code description, it’s a good idea for your documentation to be more specific, particularly if the payer requests your records.

Keep in mind that low back pain is generally a symptom of a condition. As such, there may be more specific codes which can be used (e.g., M50-, M51-) to describe a more definitive diagnosis. While the new vertebrogenic code appears to describe pain caused by problems with the endplates rather than the discs, it is still a symptom code.

New Code for Cervicogenic Headache

Last year code R51 was expanded to separate out an orthostatic (positional) headache (R51.0) from other headaches. Now, there is another new headache code, but this one is NOT in the symptoms chapter. Instead, it was added to subcategory G44.8 “Other specified headache syndromes” which is in Chapter 6 “Diseases of the nervous system (G00-G99).”

A cervicogenic headache is a type of headache resulting from referred pain perceived in the head from a source in the neck. A cervicogenic headache is a secondary headache resulting from a disorder of the cervical spine and its component bone, disc, and/or soft tissue elements. It is usually, but not invariably, accompanied by neck pain. Although this code was requested so that the Division of Health Care Statistics (DHCS) could track this specific condition, which is periodically gathered in their surveys, it may be used by others where applicable.

Even though there is an instructional note to “code also” any associated cervical spinal condition (if known); this is in reality, a secondary headache and it is likely that the causational condition should be reported first (e.g., M99.01 “Segmental and somatic dysfunction, cervical region”). However, at the time of publication, there has been no specific guidance released for this code in relation to chiropractic care.

New Codes for Non-Radiographic Axial Spondyloarthritis (nr-axSpA)

Axial spondyloarthritis is a type of inflammatory disease that causes joint inflammation or arthritis which primarily affects the pelvic joints and/or the spine. Spondyloarthritis may also affect the limbs (peripheral spondyloarthritis) and even cause inflammation in the eyes, gastrointestinal tract, and areas where ligaments and tendons attach to the bones.This condition is different from ankylosing spondylitis (also known as radiographic axSpA) in that there is not enough significant damage to the joints to be seen in an x-ray, hence the name “non-radiographic.” However, literature suggests that nr-axSpA can evolve into ankylosing spondylitis (AS).

Last year new codes were created (M46.8- “Other specified inflammatory spondylopathies”) which could be used for non-radiologic axial spondyloarthritis; however, the presenter requesting the code change was concerned about the potential to miscategorize lumbar disease (i.e., M46.84 or M46.86) as well as the fact that they were not specific enough to accurately describe and track nr-axSpA. As such, an entire new subcategory was created (i.e., M45.A- “Non-radiographic axial spondyloarthritis”), which is reported by region (e.g., M45.A6 “Non-radiographic axial spondyloarthritis of lumbar region.”)

While it is entirely possible that this could be a primary diagnosis, when it comes to CMT services and based on previous payer policies, even if the patient has a confirmed diagnosis of nr-axSpA, it will probably be reported secondarily to the segmental dysfunction codes in subcategories M99.0- and M99.1-. 

Social Determinants of Health (SDOH)

With the addition of SDoH to the Risk portion of “Medical Decision Making” (MDM) scoring for Office or Other Outpatient Services (99202-99215), it wasn’t a big surprise that nearly all of the requested additions to the current SDoH codes in ICD-10-CM (Z55-Z65) are being implemented. Some of the new codes are:

  • Homelessness: Created a distinction between sheltered and unsheltered homelessness.
  • Housing Instability: Created specific codes to define both the broad risk and the specific risk of certain types of housing instability that potentially lead to homelessness (e.g., pending foreclosure.)
  • Education: Created a new code for “Less than a high school diploma.”

Historically speaking, payers haven’t required that this information be included on a claim form. However, the change to MDM scoring might bring about some changes; particularly in the case of homelessness or housing instability. If these are situations that your practice sees regularly and that affect patient care, it might be helpful to include that information in the documentation, even if not required by the payer.

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