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."