Breaking the Codes

physical therapy billing_ICD-10Breaking the Codes

For physical therapists, ICD-10 coding changes are fast approaching

How should Shannon prepare for the switch to ICD-10 reporting codes?

“I think you’ll find that the exercises will really make a difference for you,” Shannon told her last patient of the day. “But only if you do your part. You come in a couple of times a week, but you need to do these exercises every day.”

Her warm smile took any sting out of the words, but she shook her head as she carried the patient’s file to the office.

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“You know, Theresa, my work would be a lot easier if everyone followed through on their programs,” she said. “It’s human nature, though — the temporary pain of doing the exercises is much stronger than the long-term pain of lessened mobility, even though that’s much worse. than having to do the exercises.”

Theresa agreed. “Procrastination is normal. And speaking of procrastination…”

“Don’t give me that look! I know we have to switch to the new ICD codes, but the deadline is not till October 1, 2014. We have time.”

“Let’s see… eight months. So how long have you been thinking about redecorating the practice?”

“Fair point,” Shannon laughed. “It’s probably been close to a year. But that’s not just a little update. I have to make a lot of decisions, come up with the funds, get input from a bunch of people –”

“I have a feeling this reporting change is going to be like that, too,” said Theresa. “I’m not sure exactly what’s involved, but the other office managers have been talking about it and it sounds major.”

“How many different codes do we use?” Shannon asked. “I noticed that the new codes include laterality, but we’re performing a limited number of procedures, right?”

“I get what you’re saying, but one thing I know is that the new codes have seven digits instead of five. That’s a change that will affect everything — scheduling as well as billing. I don’t know if the software we’re using right now can handle it.”

watch the ICD-10 webinar recodring now

Shannon frowned. “I see what you mean. This change might have more implications than I’ve been considering. Okay, we’d better carve out some time to go over the regulations and figure out what needs to be done.”

Theresa pulled a calendar over to her. “That’s part of the problem. You don’t really have any time — our new push for profitability is a great thing for the practice, but it hasn’t freed up any hours in your schedule. Nor in mine.”

The two women stood and looked at one another for a moment.

“I guess it’s a good thing that we have till October,” Shannon said ruefully. “It may take us a while just to get a handle on how the reporting change will affect us.”

How should Shannon prepare for the switch to ICD-10 reporting codes?

Want more information on ICD-10? Watch our ICD-10 webinar recording!

Physical Therapy Compliance | Stay compliant with ICD-10

Physical Therapy Billing_ICD10TransitionTipsTools

The International Classification of Diseases, “ICD Codes” were originally developed to track how people died. In 1948, just after the creation of the World Health Organization, a committee was put together to establish one version to represent all countries. Subsequently ICD codes were used to track diseases and injuries and to find patterns that might show an epidemic could be coming, as well as to track the general health of people. Today ICD codes are not only used for this purpose, but for medical billing in the U.S.

The transition form ICD-9 to ICD–10 was agreed upon internationally to improve electronic communication by adding specificity to both diagnosis codes and Current Procedural Terminology “CPT” codes. Everyone covered by HIPAA must transition to ICD-10. The new codes are fundamentally different because they contain information that characterizes anatomic site, severity and other clinical details. The result is that diagnosis codes grow from 13,000 to 68,000, while CPT codes grow from 11,000 to 87,000. (CPT codes will only be changing for hospital inpatient billing. Outpatient providers and other clinicians will continue to use the existing CPT Procedure Codes together with the ICD -10 codes for billing.)


  • It is 30 years old.
  • Lacks details on patients’ medical conditions
  • Lacks details on procedures and services performed on hospitalized patients
  • Uses outdated and obsolete terminology
  • Uses outdated codes that produce inaccurate and limited data
  • Is inconsistent with current medical practice
  • Not able to describe diagnoses and inpatient procedures of care now delivered


  • Incorporates much greater specificity and clinical information
  • Improved ability to measure health care services.
  • Increased sensitivity when refining grouping and reimbursement methodologies.
  • Enhanced ability to conduct public health surveillance and audits.
  • Over time a decreased need to include supporting documentation with claims. (Initially more supporting documentation may actually be required.)
  • Includes updated medical terminology and classification of diseases.

ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM. These codes allow for a much greater degree of clinical detail and afford practitioners a better understanding of their patients’ medical condition. This should lead to more customized treatment plans and better tracking of outcomes.


ICD-10-CM has many new features allowing for a greater level of specificity. These include:

  • Combination codes for conditions and common symptoms or manifestations
  • Combination codes for poisonings and external causes
  • Added laterality
  • Added extensions for episode of care
  • Expanded codes (injury, diabetes, alcohol/substance abuse, postoperative
  • complications)

Practice owners are faced with many challenges right now; RAC Audits, G Codes, and PQRS to name a few. ICD – 10 is yet another potential pitfall for your practice. Being proactive in managing your business has never been more important. Here are some suggestions to ease the transition to ICD – 10.

  • Improve Documentation Now:
    • ICD – 10 Codes will have a ripple down affect throughout many areas of your practice including payment and audits. Therefore they must be as accurate as possible.
    • Accurate coding cannot be achieved without the clinicians’ effort to provide good documentation.
    • The detailed information that is required to code using ICD 10 is also needed to create Treatment Plans that comply with Medicare requirements including “G Codes”. Clinicians must ensure that sufficient information is included in the medical record to satisfy these requirements.
  • Develop the Relationship Between Coders (Billers) and Clinicians
    • Clinicians do not need to understand all of the intricacies of billing and coding, and billers / coders do not need to understand all of the clinical / medical — but they must work together to ensure optimal accuracy.
    • Clinicians must accurately, precisely, and comprehensively document the patient’s medical condition and level of functional impairment and the procedures performed.
    • Billers need to understand basic anatomy and the pathology of conditions commonly seen in a therapy practice to better understand the clinicians’ documentation.
    • Anything that practices and providers can do to improve and facilitate the working relationship between therapists and billers will contribute to a smoother transition.
    • Ultimately, practices want to encourage clear documentation by clinicians and accurate coding by billers.
  • Institute Strategies for Training
    • Practice owners need to understand the impact of ICD – 10, identify the steps necessary to implement the move to ICD – 10 and the challenges that need to be addressed including people and technology.
    • Designate a specific person responsible for moving this transition through the organization.
    • Develop a timeline for training for office staff and clinicians starting at least six months before the implantation deadline (currently October 1, 2014).
    • ICD-10 codes can not be used in actual billing until the official start date, however most payers have a process in place that allows for testing in advance. Effective testing will prevent interruptions in cash flow once the official transition is made.
  • Locate the Resources for Help
    • Official resources are available at the Centers for Medicare & Medicaid Services (CMS) ICD-10 website. The site has a number of free papers to help in implementation, and includes all the official codes and guidelines. Implementation guides for both small and large practices are available that walk the user through the process.
    • There are 2 major, well-respected, accredited societies that offer training for coders/billers: the American Association of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).
    • Genco Healthcare Management is working closely with the team at Billing Dynamix to provide training and other services to their clients. We can be reached at 914-713-3606 or by email

We are grateful to Joseph C. Nichols MD whose writing for Medscape Education in 2012, inspired some of the suggestions contained in this blog posting.


Physical Therapy Billing | Tips for a smooth ICD-10 transition

physical therapy billing | icd-10 codesCenters for Medicare & Medicaid Services (CMS) offers some suggestions to ensure that your practice has a smooth transition from ICD-9 to ICD-10.  As your physical therapy practice management solution bestPT wants to ensure that you are ready for the change over before it takes effect.

Your SPOC is ready to help you plan for your practice’s transition and your Team’s success.
Assembling an ICD-10 Project Team

Assembling an ICD-10 Project Team to oversee your organization’s shift to ICD-10 is instrumental to a successful transition. This team will be responsible for overseeing the ICD-10 planning and implementation process.

Select Your Team

Since ICD-10 will affect nearly all areas of your practice, project teams should consist of representatives from key areas of your organization, including:

  • Senior Management
  • Health Information Management/Coding
  • Billing/Finance
  • Compliance
  • Revenue Cycle Management
  • Information Systems and Technology

This multi-disciplinary team provides the cooperative environment necessary to address your organization’s needs. If you run a small business or practice, several of these functional areas may rest with the same individuals, making your transition team smaller.

Appoint a Project Manager

Once members of the project team have been selected, appoint one team member to serve as the project manager. As the manager, he or she will be responsible for establishing accountability across the ICD-10 implementation team and making business, policy, and technical decisions.

Your Team’s Initial Tasks

With an established project team and a designated project lead, you’ll be ready to begin planning for ICD-10 implementation. Project teams should:

  • Establish regular check-in meetings to discuss progress and address any issues.
  • Conduct an ICD-10 impact assessment to help you determine how the transition to ICD-10 will affect your organization, and allow you to schedule and budget for all ICD-10 activities.
  • Plan a comprehensive and realistic budget. This should include costs such as software upgrades and training needs.
  • Identify and ensure involvement and commitment of all internal and external stakeholders. Contact vendors, physicians, affiliated hospitals, clearinghouses, and others to determine their plans for ICD-10 transition.
  • Develop and adhere to a well-defined implementation timeline that makes sense for your organization.

Communicate Regularly

Remember to communicate regularly with your entire ICD-10 project team! Keeping the lines of communication open will help make sure everyone is kept up to date on the implementation progress. It may be helpful to establish and circulate a calendar of internal tasks, milestones, and deadlines to help keep day-to-day activities running smoothly and on schedule.

Keep Up to Date on ICD-10.

Please visit the ICD-10 website for the latest news and resources to help you prepare! Don’t forget to open a ticket to your SPOC with any specific questions you may have!

Physical Therapy Billing | How to Avoid Common Version 5010 Claims Rejections

Physical therapy billing | ICD-10

The deadline for the Version 5010 upgrade was Jan. 1, 2012 and the enforcement discretion period for all HIPAA-covered entities to complete their upgrade to the Version 5010 electronic standards ended on June 30, 2012. The Version 5010 transaction standards have different requirements than those of Version 4010 and 4010A. There are a few things to keep in mind for processing your Version 5010 claims, which should help avoid unnecessary rejections:

  • ZIP Code: You need to include a complete 9-digit ZIP code for the billing provider and service facility location. You should work with your vendor to make sure that your system captures the full 9-digit ZIP.
  • Billing Provider Address: You need to use a physical address for your Billing Provider Address. Version 5010 does not allow for use of a PO Box address for either professional or institutional claim formats. You can still use a PO Box, however, as your address for payments and correspondence from payers as long as you report this location as a pay-to address.
  • National Provider Identifier (NPI): You were previously allowed to report an Employer’s Identification Number (Tax ID) or Social Security Number (SSN) as a primary identifier for the billing provider. For Version 5010 claims, however, you are only allowed to report an NPI as a primary identifier.

For additional help with your Version 5010 upgrade and Medicare claims, you can contact your Medicare Administrative Contractor (MAC). The MACs work closely with clearinghouses, billing vendors, and health care providers who require assistance in submitting and receiving Version 5010 compliant transactions. If you experience difficulty reaching a MAC, you should send a message describing your issue with “5010 Extension” in the subject line.

The Medicare Fee-For-Service group has created a fact sheet that provides guidance to help providers troubleshoot some of the difficulties they may experience with Version 5010 claims processing and links to each of the MAC websites, including lists of the top 10 edits for Version 5010 claims.

Keep Up to Date on Version 5010 and ICD-10.

Please visit the ICD-10 website for the latest news and resources to help you prepare!