Recently one of the health plans delegated to us the task of guiding our providers on the proper use of the seventh character in codes related to trauma and other diseases, where a particular occurrence is identified, i.e., the initial or subsequent sequela of the disease.
It is important for therapists and physiatrists to comply with these guidelines to determine a correct value of the Medicare Risk Adjustment Factor. This value determines the allocation of funds for Medicare, therefore the data coding that Medicare undergoes is significantly affected by the 7th digit of the ICD10 code. If for any reason a finding is encoded as initial "A" and the documentation or event justifies a subsequent "D" finding, we would be receiving funds that are not appropriate for the patient's condition; and therefore, we would be subject to signs and / or recoveries by CMS.
We have noticed that many providers who are using a ICD-9-CM to ICD-10-CM translators, are prone to such error. According to CMS only 5% of the translations between the two classifications are accurate; i.e., there's a 95% possibility of incorrect codes when using these programs. Therefore, we urge you to manually encode ICD-10-CM.
A patient is diagnosed with a traumatic rupture of an ACL and presents herself for outpatient PT. Although the referral comes as ACL rupture (S83.511A), knee pain and difficultness to walk, the proper treatment code requires D in the 7th digit ( S83.511D) because the therapy treatment for this patient is not an active treatment for ligament rupture but rather it is for symptoms of knee pain and difficulty in moving.download