‘Tis the season for changes, including CMS final rule releases and payer updates! And with the latest CMS update to the tenth edition of the International Classification of Diseases (ICD-10), some codes are on the chopping block and others are being added. So rehabilitative therapists will need to pay attention.

Here are all the highlights you need to know about the latest ICD-10 update from CMS’s approved code list, effective October 1, 2021 through September 30, 2022.

What happened to M54.5 (low back pain)?

For physical and occupational therapists, lower back pain (ICD-10 code M54.5) is one of the most reported diagnoses in the industry. However, M54.5 was cut in the most recent updates from CMS.

The popularity of this code could be part of the reason why it is no longer accepted. ICD-10 updates annually to improve specificity around diagnoses, and while M54.5 is very common, it isn’t very specific. As the APTA’s Alice Bell (PT, DPT) shared, changes like this will be ongoing.

So where does that leave therapists?

Luckily, some existing and newly added codes can offer more specificity. Rehab therapists will have to find the code that best fits their patient’s case.

M54.5 code replacements

Looking for a more specific low back pain code? Try one of these variations*:

  • 2- (lumbago due to intervertebral disc displacement)
  • 4- (lumbago with sciatica)
  • 50 (low back pain, unspecified)
  • 51 (vertebrogenic low back pain)
  • 59 (other low back pain)
  • 012 (low back strain)

*Check for Exclude1 notes for all the variations provided.

As Alice Bell told the APTA: “In the ICD-10 world, specificity is key. 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.”

What else has changed with ICD-10?

Besides low back pain, other codes have also been removed and updated. Speech therapists, especially, should be aware of the following changes:

  • Removal of code R05 (cough)
    • Instead, choose from these new codes:
      • 1 (acute cough)
      • 2 (subacute cough)
      • 3 (chronic cough, persistent cough, refractory cough, unexplained cough)
      • 4 (cough syncope)
      • 8 (other specified cough)
      • 9 (cough, unspecified)
  • Removal of code R63.3 (feeding difficulties, picky eater)
    • Instead, choose from these new codes:
      • 30 (feeding difficulties, unspecified)
      • 31 (pediatric feeding disorder or dysfunction, acute)*
      • 32 (pediatric feeding disorder or dysfunction, chronic)*
      • 39 (other feeding difficulties, picky eater, feeding problem for elderly or infant)
  • Addition of new category U09 (post COVID-19 condition)
  • Addition of new code U09.9 (post COVID-19 condition, unspecified, or post-acute sequela of COVID-19)*

* Check for Exclude1 notes for all the variations provided. Codes also require, if applicable, associated conditions.

Earlier in 2021, we also saw the addition of a handful of new codes around COVID-19 (U07.1) and related conditions. For more information on recent ICD-10 changes, check out our new ICD-10 guide.

Preparing your billing team for new codes

While CMS released these changes in September 2021, the changes apply to all payers. However, some non-government payers may take time to adjust. If you use any of the new codes on claims for private or commercial payers, be prepared to potentially see some denials.

But hold steady—it is always best practice to follow CMS updates when it comes to ICD-10. However, keep in mind that while the codes may change, payer coverage for those conditions may not. As always, check with the payer on specific coverage if your billing team is unsure before filing a claim.

Fall is a great reminder that change is always inevitable—both in the natural and bureaucratic world. Stay tuned for more, as CMS has plenty of changes coming in the new year.

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