One of PT’s Most Common Diagnosis Codes is going BYE-BYE

This time of year tends to be very active for changes within the physical therapy profession.   Not only is the PTA differential getting closer to a decision, but there are updates with CCI edits and ICD-10 codes.  Every year at this time, CMS publishes a new set of ICD-10 codes that will apply to all healthcare professions, not just strictly physical therapy.  CMS will go through all the ICD-10 codes and remove ones that are no longer necessary and add new codes and new language.  Take special note that these changes will be taking place October 1, 2021, which is only mere days away.

ICD-10 that will affect PT’s the most

The majority of outpatient physical therapy practices have one major thing in common; low back pain is the staple diagnosis of patients we see.  After all, low back pain is the most common type of pain reported, with about 25% of U.S. adults affected by low back pain.  Doctors, nurses, physical therapists, and all other healthcare professionals will no longer be able to bill M54.5 come October 1st.  CMS is removing M54.5 from the list of payable ICD-10 codes.  I don’t know about you, but our physical therapy practice uses this diagnosis code all the time!

This not only means that new patients coming into your PT clinic with low back pain need to be given a different ICD-10 code, but also all existing patients that currently have M54.5 designated as a code in their chart must be updated on October 1st.

We knew this was coming.

Way back in 2015, when the ICD-9 was a thing of the past and ICD-10 codes came into play, this was the beginning of adding more drilled down, specific coding for patient diagnoses.  We made the adjustments then and we can make them now; this shouldn’t be a major ordeal for most physical therapy clinics fortunately.  The good news is that more specific low back pain ICD-10 codes will be replacing the deletion of M54.5!

S39.012 – Low back strain; strain of muscle, fascia and tendon of lower back

M51.2 – Lumbago due to intervertebral disc displacement

M54.4 – Lumbago with sciatica

M54.50 – Low back pain, unspecified; multiple sites in spine

M54.51 – Vertebrogenic low back pain

M54.59 – Other low back pain

These codes should suffice in replacing the more broad M54.5 low back pain code.  However, it is going to take some adjustment on our part.

Keep an eye out on denials

While we know these changes will take effect on October 1st, we also realize that it is going to take some time for all of the insurance payers to catch up and actually implement the changes themselves.  In the meantime, here are a couple things you will need to look out for:

  1. If a claim after October 1, 2021 is denied with the newly added ICD-10 codes, you’ve got to appeal the claim.
  2. If you accidentally bill M54.5 and the claim is paid, you’re more than likely to get a take-back once they figure it out.

You have a week now to get your staff trained up and understanding what the new codes will be and how to make these changes for patients currently in an active plan of care under M54.5.  Go!

If you’re a HENO customer, don’t fret!  We’ve made it easy for you to know (with one click!!) just how many active patients you have actively that are M54.5 diagnos

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