Question: I was recently made aware that the diagnosis (ICD-10) code for back pain, M54.5, was deleted and three new codes replaced it. What do these new codes represent and how do I assure that I am using the best coding for a chiropractic provider? Also, are there any other codes that changed with the recent update?
As occurs every Oct. 1, there are updates to the ICD-10 coding system. Some years, this update makes no difference to the common codes billed by chiropractic providers, but most years there are at least a few; and this year – like last year – does so, particularly the code for which most insurances, including Medicare, will reimburse chiropractic services.
Last year, there were updates to common headache R51, revised to two new codes: R51.0 orthostatic headache and R51.9 unspecified headache. This update was essentially the only change to commonly used codes by a chiropractic provider. This year, there are several code changes that took effect Oct. 1, 2021.
New Codes for Back Pain
As referenced, this year, the code for back pain has been updated. M54.5 was deleted and three new codes were added:
- M54.50 unspecified back pain
- M54.51 vertebrogenic back pain
- M54.59 other back pain
Back pain generically has these approximate synonyms:
- Acute low back pain
- Acute low back pain less than three months
- Chronic low back pain
- Chronic low back pain more than three months
- Low back pain in pregnancy
- Low back pain without radiculopathy
- Lumbar back pain acute
- Lumbar back pain chronic
- Mechanical low back pain
This can encompass a broad spectrum of the symptomatology of back pain. But what does each of these new codes reference?
M54.50 back pain, in simplest terms, means there is back pain, but no definitive causation or reason is identified. It may be used to identify the secondary effect of subluxation to the lumbar region.
M54.51 vertebrogenic back pain is to identify pain that is related to a vertebra / the spine. This may appear tailor-made for a chiropractor at first glance, but it is to identify vertebral endplate pain.
Note that there are much more specific codes based on the spinal nature of pain in the lower back (sprain, strain, radiculopathy, etc.), which can be used for a more specified identification of pain in the lower back.
M54.59 other back pain would be used in instances in which the specific cause can be identified, but otherwise has no specific code. For instance, this code could be used for conditions such as facet syndrome. Unlike codes that state "unspecified," this code means you can specify the origin. For example, internal or visceral causation, such as a kidney stone causing back pain, would be an appropriate use of this code.
While pain codes are correct, I would suggest when possible to diagnose what is causing the pain and not the pain alone. For instance, low back pain would be accurate for pain as a result of a sprain; however, sprain would be the better choice, as it provides more detail and allows the care that would be necessary to be easily defined by the coding.
Note that you would not need to code pain with a sprain, as it is inherent. Of special note, you cannot code a low back pain (or any spine pain) code with a spinal disc code, as that combination will be denied; those codes are "exclude 1" codes, meaning they cannot be used together. Just like sprain and pain, there is no need to indicate pain with a disc diagnosis.
Even vertebrogenic back pain would be nonspecific when you have a radiology report identifying lumbar degenerative disc disease or spinal stenosis. Those diagnoses would be more specific than vertebrogenic low back pain. When you can identify why there is low back pain, that is the code you should be using.
New Headache Code
There is also an additional, less publicized, but equally important, covered diagnosis for chiropractic. There is a new headache code: cervicogenic headache G44.86. This code represents a further identification of headache by type, identifying cervicogenic as an origin or cause. Note that there are multiple codes for headache including specific diagnoses: migraine, tension, traumatic, vascular, cluster, etc.
Cervicogenic relates to a pain that develops in the neck, although a person feels the pain in their head. Cervicogenic headaches are secondary headaches, meaning there is specific underlying causation from the neck, which may include muscle tension.
Other Codes That May Apply
There are also new codes for "non-radiographic" spondylarthritis, M45.A0 to M45.AB. Back pain is the hallmark of non-radiographic axial spondyloarthritis. "Non-radiographic" means the disease causes symptoms, but there is no visible damage on X-ray, the way there is with a related type of inflammatory arthritis called ankylosing spondylitis.
There are also codes for Sjogren's syndrome, having an identification of such, and not just "sicca" syndrome, M35.00 to M35.09. While not likely a primary reason for care, note that this syndrome is often part of rheumatoid arthritis, and would be a complication and comorbidity affecting the care necessary.
There are also updates to codes for cough that identify cough with greater specificity. While these codes are not typically used for reimbursement, there may be instances for which identifying a complication or comorbidity can identify barriers to a patient's recovery. The new codes for cough are R05.1 to R05.9.
Billing Considerations
It is important to always verify your codes are current and to the highest level of specificity. This is a fancy way of saying that if you are diagnosing back pain, for example, you need to now have five characters instead of four; just like in 2020, when the headache code went from three to four characters (R51 to R51.0 and R51.9).
The 2022 code updates took effect on Oct. 1, 2021, which means any date of service on or after that date must use the new codes. Dates of service before Oct. 1, 2021, require the older versions. At this time, it is not likely you are still billing for services that far back, but note that the date of service determines the code, not the date the service is billed.
There are now 72,748 ICD-10 codes for 2022, with 159 codes added, 32 codes deleted and 59 revised. This article is limited to focusing on the codes that have implications for chiropractic providers.
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