Why ICD-10 Has Been Bad For PI Cases (& What to Do About It)

Historically, chiropractors have enjoyed good success in personal injury work but the changes brought on by ICD-10 have not seemed to help in the matter and from the emails and comments we receive at our chiropractic seminars, it appears there is a good portion of the profession made significantly worse by ICD-10 when it comes to chiropractic personal injury work.

Fortunately, it’s a fixable mess that’s been made – at least to a degree. So, let’s dive into the problem at hand and work on some improvements.

The Principles of Devaluation At Work in ICD-10

The first problem is one of basic devaluation.  In other words, some components of the “currency” of a motor vehicle injury claim is made less by the simple principles of devaluation which run parallel to the same principles of financial devaluation.

For example, if a country attempts to solve its financial problems by simply printing more money, that generally does not increase the value of its currency but decreases it.

Moving from basic economics to the medical marketplace a similar phenomenon  is occurring. Thanks to ICD-10, more “printing” is going on in the form of thousands of additional diagnosis codes. While the “printing” of more codes did not directly cause the problem, their affect on the marketplace is what produces lower value when payers use computer generated claims processing software to establish a value for that chiropractic personal injury claim.  And the fact of the matter is that the vast majority (over 80%) of auto insurers are ALL using some form of claims processing software – with most using “The Big 4” (Colossus, Claims Outcome Advisor, Injury Claims Evaluator and Injury IQ).

How ICD-10 is Impacted By Colossus and Claims Processing Software

Here’s why ICD-10 has the potential to negatively affect claims value at least for chiropractors who don’t pay attention to what’s going on.

Colossus and its claims processing counterparts all work utilizing the same basic methods.  As data from the injury claim are input into the computer, “points” are assigned for each variable, a proprietary formula is applied and a value for the claim is generated.

That claim value then dictates how much care the PI Payer is willing to ultimately reimburse, when they call in the IME troops to argue, how much settlement they are willing to offer for damages and/or if and when the payer will choose to litigate.

Obviously, all of those decisions make a HUGE impact on our lives as chiropractors and the lives of our patients and here’s the bad news:  ICD-10 isn’t helping us.

How?  Well, one of the variables that is assigned “points” in claims processing software and ultimately contributes to the value of the claim is your ICD-10 diagnosis codes.  And, the effect is significant.  Here’s why:

Why ICD-10 May Be

In the simpler days of ICD-9, those codes also affected the value of a claim.  But there were fewer codes and fewer choices and each code was worth more. For example, let’s say you coded a cervical sprain/strain in ICD-9 and that code was assigned “10 points” (no one knows the exact actual value because payers won’t tell you, so just use this for example purposes) towards the total value of a claim. Technically, speaking one code in ICD-9 is simpler than ICD-10 which requires you to utilize two codes in ICD-10 to communicate the same diagnosis: one for a cervical sprain and (since the codes are separated) one for a cervical strain.

Not only was it easier and less prone to error (only have one code vs two) but the value changed (but no one told you).  After all, theoretically, if a sprain/strain was 10 points in ICD-9, the sprain is no longer 10 points in ICD-10 because that would overinflate the value of that one code. But the sprain could potentially be 5 points, so that the equivalent ICD-10 codes for both sprain and strain still equal 10 points.

The Very HUMAN Problem Of Changing to ICD-10

All of this sounds fine in theory as 1 code equaling 10 points sounds the same as 2 codes of 5 points combined to equal 10 points – until you factor in human error!

The fact of the matter is when you separate strain and strain, some folks will not diagnose both because clinically they don’t see it.  That decreases the value because now you only score 5 points, whereas in ICD-9 you would have scored 10. Additionally, some folks won’t code sprain and strain because they miss it or are lazy (Hey! It’s real! Two things to remember vs one!).  The end result is the same = decreased “points” or claims value.

If this sounds like a bit of a nightmare, hold on.  It gets worse.

Electronic vs Human Claims Processing

In most commercial insurance claims processing, everything is electronic.  Therefore, the diagnosis code inputting is done by a computer that reads your electronic claims submission, enters the data and makes judgements accordingly based on your patient’s benefits, medical policies, etc.

On the other hand, many (if not, most) auto insurance payers process claims VIA PAPER. This is bad news on two levels.

First, paper processing means that there’s a human on the other side of the fence who is working for the insurance company.  When PI payers utilize Colossus or one its able-bodied equivalents, there is code input going on.  In other words, someone must enter the codes into the claims processing software and yes, they are far more likely to “accidentally” miss two codes vs one or leave out codes altogether.

Sound sinister?  Even truly accidental mistakes can easily manipulate your claim value by significant amounts.

Wait it gets still worse.

Diagnosis Hierarchy Damages

When auto payers process your chiropractic personal injury claims, each diagnosis codes is assigned a hierarchy that contributes to the value of your claim.  So, for example, if you code something fairly minor such as cervicalgia vs something more significant such as a cervical disc displacement, the claims processing software assigns more points to the serious condition (disc) and fewer to the less serious condition (neck pain).

If you’re not aware of this as a chiropractor, you can easily do yourself and your patients a disservice by unintentionally “earning” less care in the computer’s proprietary formula and decreasing the value of your case.

Even if you are aware of this, you still have a human on the other side of the fence who can make mistakes, input the wrong hierarchy or even input incorrect ICD-10 codes for your conditions.  Why?  Because all of your conditions on a paper based claim don’t live on the paper based claim!  They may exist in your note and you may or may not give both the code descriptor (i.e. cervicalgia) and the actual code (M54.2).  Therefore, the inputter can put in the wrong code and/or the wrong description and/or the wrong hierarchy (which codes are the most severe problem).

I hate to say it, but it can get still worse.

Cheat Sheet Problems and New Condition Problems

Admittedly, many chiropractors (and their medical counterparts) attempted to quickly learn ICD-10 through use of “cheat sheets” or common code “reference sheets” which gave lists of commonly used codes.

The problem with that is the short list is not always the thorough list or the best list to use, especially if a code not present on the short list has a higher “point value” than a code on a full list.

So while code references may be expedient, they should not be used exclusively if you want to communicate best regarding your patient’s motor vehicle injury.

And one final problem (for today).

The Newness of the Numbers

The last problem we will address (at least for now) is the indisputable fact that with the addition of thousands of new ICD-10 codes, there is no previous “value” assigned to the codes based on past experience.  In other words, the reason we know the code hierarchy is because we’ve learned over time which codes payers think are more or less serious.

But in the case of brand new codes that didn’t previously exist we have no data.  And therefore, we are forced to learn through the school or hard knocks.

What that means in PI land is that you are experimenting with new codes that may or may not help your case value.  Eventually, we will learn.  But for now, we are the guinea pigs and our patients and payments may suffer in the interim.

What to Do Next

Some of the challenges mentioned above are within your control, while others you may not be immediately able to take action on.  But here are some recommended steps:

1.     Utilize proper hierarchy – if you think all codes are created equal, claims processing software is having a field day destroying the value of your claims.  Instead, code to the highest level of severity for applicable problems and don’t get into the lazy pattern of just coding lower level diagnoses because they are simple.

2.     Check Documentation and Claims For “Left Behind” Codes – in the event that you are coding things such as sprain and strain which were formerly one code in ICD-9, be sure that you are including both codes in ICD-10 (if applicable) so that you are not de-valuing your own claim.

3.     List ALL applicable diagnosis codes in your documentation – recognize the limitations of the paper claim and make sure that your notes clearly state all the diagnosis codes relevant to the case.

4.     Watch AND Learn – understand that ICD-10 is still a codeset in the making.  Watch for problem codes, notice patterns and keep learning!  No one has ICD-10 completely figured out yet, because it is still evolving.  At the start of 2017, more codes were added and more are in the works. So be prepared to keep learning.

 

Want help with all the above and MUCH MORE?  Consider attending our Chiropractic Personal Injury POWER Seminar – where I’ll be teaching you how to RAPIDLY improve your MVA coding, documentation, case management, billing and business strategies for a bigger, better, more profitable PI practice!  Click the link above for more details and to register.

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