The orangest season of the year is almost upon us—but autumn heralds far more than just colorful leaves, cooler weather, and pumpkin spice everything. It also signals the beginning of compliance season: the time of year when CMS publishes a large number of changes to the Medicare program and other healthcare rules and regulations.
This year, alongside the 2022 proposed rule and the quarterly NCCI edit changes, CMS announced some updates to the ICD-10 manual—and you’re gonna want to know about them. Here’s what’s happening.
ICD-10 code M54.5 is getting the kibosh.
Every year, CMS publishes updates to the ICD-10 manual, deleting unnecessary codes, adding new ones, and revising language as-needed. This August, CMS published its latest round of ICD-10 changes—including the deletion of ICD-10 code M54.5, low back pain, effective October 1, 2021.
That means providers cannot use M54.5 to specify a diagnosis on or after October 1—and existing patients with the M54.5 diagnosis will need to be updated to a valid ICD-10 code. This is one of the most commonly billed codes in the rehab therapy industry, and our compliance experts predict that this change will heavily affect the coding habits of many (if not most) rehab therapists.
That’s not the only ICD-10 code on the outs.
The deletion of M54.5 is not the only one that may cause waves for rehab therapists (even though it will cause the biggest disturbance). The WebPT team also identified two more codes that are commonly used by our Members and are also slated for deletion:
- R05 – Cough
- R63.3 – Feeding Difficulties
Providers will need to get specific, using more detailed (and sometimes new) ICD-10 codes to describe low back pain.
So, here’s the real question: How the heck can CMS justify deleting such a commonly used code? Well, CMS has explained that it’s deleting M54.5 because it lacks specificity (and we all know how important coding specificity is to ICD-10). To supplement this low back coding deletion, CMS suggested that providers use other, more specific codes—some which you may recognize, and some of which are totally new. Here are some potential code replacements that you can use beginning October 1:
- S39.012, Low back strain
- M51.2-, Lumbago due to intervertebral disc displacement
- M54.4-, Lumbago with sciatica
- M54.50, Low back pain, unspecified
- M54.51: Vertebrogenic low back pain
- M54.59: Other low back pain
Please note that using S39.012, M51.2-, or M54.4- in addition to M54.5- will likely result in an Excludes1 edit.
Prepare for payer pushback.
When CMS edits the ICD-10 manual, those changes apply to all payers—Medicare, state, and commercial alike. That said, some commercial payers don’t have the best track record when it comes to applying these changes in a timely manner. So it’s possible that come October 1, you may bill a new code (e.g., M54.51) and receive a denial until the payer updates its policies. Alternatively, even if you successfully bill M54.5, you may face retractions from the payer somewhere down the line. Best practice is to stick to the latest version of the ICD-10 manual and prepare to appeal, appeal, appeal.
CMS is kicking off this compliance season with a bang—but even more changes are slated to come down the pipeline with the 2022 final rule. Keep your eyes on the blog for the latest and greatest info that you need to know.
One of the most commonly billed codes in the rehab industry is about to disappear: Beginning Oct. 1, the International Classification of Diseases code for low back pain — M54.5 — will no longer exist in the ICD-10 listings. The more general code is being replaced by a series of codes related to LBP aimed at providing greater specificity around diagnosis. The changes come as part of annual updates to the ICD-10 that are implemented every October. The replacement
codes, some of which are new, include designations for low back strain, lumbago due to intervertebral disc displacement, lumbago with sciatica, vertebrogenic LBP, unspecified LBP, and other LBP. The codes must be used for patient encounters and discharges from Oct. 1, 2021, through Sept. 30, 2022. The entire updated ICD-10 code set can be found at the U.S. Centers for Medicare & Medicaid's
ICD-10 webpage. APTA has also updated its guidance documents available on the association's webpage on identifying the correct ICD-10 codes. "Specificity Is Key"
According to Alice Bell, PT, DPT, APTA senior payment
specialist, the changes are part of an ongoing push for more detailed codes — a push that providers shouldn't take lightly.
"In the ICD-10 world, specificity is key," Bell said. "It's important to avoid listing a specific code along with a less specific code for the same condition, because that kind of combination will likely lead to denials — for instance, don't use the code for low back strain with the more specific code for vertebrogenic low back pain, because there's a good chance payers will push back."
Some Payers Jumped the Gun
As the date for rollout of the updates neared, some payers and Medicare Administrative Contractors began requiring the new codes before the actual changeover. The result: Some providers have had claims rejected in error.
Bell says there are two ways to make things right.
"If a claim has been denied based on the updates that weren't yet in place, providers can appeal," she said. "Another approach would be to resubmit the claim with the updated codes."