For chiropractic physicians transitioning to ICD-10, most of the time they will be using chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue.) For injuries however, they’re more likely to use chapter 19 (Injury, Poisoning & Other Certain Consequences of External Causes).
Chapter 19 codes are easy to identify in the tabular list because of the “S” at the beginning of each of these codes. The “s” codes represent conditions such as sprains and strains as in the following example, S13.4XXA, Sprain of Cervical Spine Ligaments, Initial Encounter.
The confusion comes in when the code asks for a seventh character extension. These are sometimes called the encounter codes.
As you look for a specific injury code in chapter 19, you will see directly underneath the code category or “Block,” the directions that the code requires a 7th character.
S13 Dislocation and sprain of joints and ligaments at neck level
The appropriate 7th character is to be added to each code from category S13
A initial encounter
D subsequent encounter
The official guidelines indicate the following:
A – Initial encounter:
As long as patient is receiving active treatment for the condition.
D – Subsequent encounter: (CONSIDERED MAINTENANCE CARE)*
After patient has received active treatment and is receiving routine care for the condition.
S – Sequela:
Complications or conditions that arise as a direct result of a condition.
(e.g., scar formation after a burn)
Chiropractic physicians should always use the “A” character with injury codes as long as they feel the patient should be receiving “active treatment” and can show that the patient is improving with the treatment provided.
At seminars, I am often asked, “What If The Patient Comes Back To Your Office In Three Months With The Same Condition?” My answer is code “A” for active care.
To Medicare and the insurance companies, coding “D” means maintenance care and that means you will be denied payment.
When I queried the insurance companies, such as Anthem and Blue Cross Blue Shield they defer to Medicare rules.
So for now, “A” stands for active care and “D” stands for maintenance care when it comes to reimbursement from payers.
Dr. John Davenport DCM, CCSP, FIAMA, MCSP
Chief Compliance Officer
FCPA Compliance Adviser
About the Author
Dr. Davenport ran his own clinic for many years. He now provides expert witness testimony, insurance consulting, medical record audits, consulting, and online courses for healthcare providers. He also writes books and articles for trade journals, and is a sought-after seminar speaker.