ICD's Specific to Workers’ Compensation
BWC has specific requirements that are different from those common in the health care industry. Workers' compensation only covers the body part(s) and condition(s) affected by the industrial injury or illness. BWC and self-insuring employers rely on provider diagnoses to determine what conditions to allow. Specific diagnoses, including site and location are needed. The conditions reported on a First Report of Injury (FROI) should include the cause of the injured worker's symptoms and not just the symptoms themselves. Symptom codes cannot be recognized within the workers’ compensation system. Documents have been developed to provide guidance for reporting injuries and requesting additional conditions.
- International Classification of Diseases (ICD)-10 codes inappropriate for claim allowances - These are primarily symptom codes, unspecified codes and incomplete (ICD chapter heading) codes. Providers who report codes from this list may receive follow-up communication from the MCO or BWC requesting diagnosis clarification. Reporting injuries with inappropriate diagnoses delays claim allowance, treatment authorizations and provider reimbursement.
- Most frequently allowed diagnosis codes - This document includes ICD-9 codes and the alternatives that can be used in reporting with ICD-10. This is NOT a substitute for ICD-10 coding education and the use of professional coding resources, but an illustration of conditions commonly seen in workers' compensation.
Providers can use the narrative descriptions to determine the best code for reporting injuries and requesting additional conditions. Resources ICDs for billing Seventh Character Description for ICD-10 ICD-10-CM Coding and Ohio Workers’ Compensation.
What’s unique about workers’ compensation?
Issue 1: Code specificity, including location – why is that Important to BWC?
With the implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD10-CM), non-specified diagnoses submitted for allowances in claims increased. They increased on the First Report of Injury, Occupational Disease or Death (FROI) and on requests for additional allowances submitted on Completing the Request for Medical Service Reimbursement or Recommendation for Additional conditions for Industrial Injury or Occupational Disease (C-9) forms.
Many of the non-specified code submissions are ones that require laterality (right, left or bilateral). We need to know location to recognize claim conditions accurately. Please Include laterality (left, right, bilateral) with the code. It’s best to submit ICD-10-CM codes with the narrative description on the C-9 and on the FROI so everyone is clear.
BWC looks to the narrative description to code when it is necessary. Remember, do not submit symptom ICD codes as claim allowances. BWC still does not recognize symptom codes as claim allowances. That didn’t change from the ICD-9 coding processes.
Issue 2: What are BWC’s coding differences for the seventh character that addresses encounter type?
Most of the ICD-10-CM codes from the “S” and “T” categories must have seven characters in the code. BWC acceptable codes for claim allowances are coded using the seventh character “A“(initial encounter). In most cases, we will recognize it as a claim allowance for ongoing routine follow-up care. We do not need to allow the same condition again with a different seventh character as the condition and treatment progresses.
Therefore, for routine follow-up visits, the ICD-10-CM codes with the seventh character “D”, “E”, or “F”, will not be acceptable for claim allowances. Sequela or “S” - a seventh digit code character means late effect of a previous injury. BWC does not use sequela codes as claim allowances. Instead, use the code for specific complications.
What are the BWC exceptions to the seventh character encounter type usage? Fractures are the common exclusion for seventh character codes. For fractures, submit the seventh character for the ICD-10-CM codes based on the type of encounter – initial for closed or open fracture, subsequent for delayed healing, malunion or non-union. BWC will accept all seventh character encounter types (“D”, “E”, ”F”, and “S”) on bills.
Issue 3: How will BWC customize its claim/condition allowance orders?
When we legally allow a condition in a claim, we recognize that condition because of the industrial injury. With the ICD-10-CM specificity in coding to define encounter type, we decided to accept the “A” initial encounter to code the condition at inception (SEE: Issue 2 above).
For clarity in the condition allowance, you will no longer see the “encounter” portion of the ICD-10-CM code in the written description of the condition on allowance orders. The ICD-10-CM code will continue to reflect the encounter seventh digit.
Issue 4: What about traumatic v. non traumatic codes?
For BWC allowances, submit the majority of initial allowances with traumatic codes because workers’ compensation injuries are generally the result of an industrial accident. When assigning a code for an acute condition because of a trauma (injury), the ICD-10-CM code should start with the first character S or T from Injury Chapter 19. (This includes conditions such as facture, contusion, laceration, abrasion, burn, dislocation/subluxation, meniscus tear, sprain, strain, etc.)
- Example 1: pneumothorax, traumatic – occurring as a result of the industrial accident o S27.0xxA- Pneumothorax (traumatic) for injury vs. J93.83 pneumothorax (spontaneous-non traumatic)
- Example 2: Assign the ICD-10-CM code for complete/partial traumatic rotator cuff tear or strain of muscle/tendon with S46.011A (right shoulder) and S46.012A (left shoulder).
- This includes infraspinatus, supraspinatus, subscapularis and minor tears of muscle/tendon.
- For complete/partial traumatic rotator cuff capsule sprain or tear, assign a code S43.421A (right shoulder) and S43.422A (left shoulder).
Issue 5: How is BWC addressing strains (muscles and tendons) in ICD-10-CM for the back?
In ICD-10-CM, Sprain (ligament and joints) and Strain (muscle and tendon) codes are separated. This is different from coding in ICD-9. When coding back strains, there are only two codes, which are S16.1xxA (cervical strain) and S39.012A (thoracic, lumbar, sacral and or sacroiliac strain).S39.012A reads as “strain of muscle, fascia and tendon of lower back”. The BWC staff has the ability to specify the site requested by provider.
Spinal/Back Sprain and Strain Table
|Condition||ICD-9 Code||ICD-10 Code||ICD-10 Code Short Description|
|Cervical Sprain||847.0||S12.4xxA||Sprain of ligaments of cervical spine|
|Cervical Strain||847.0||S16.1xxA||Strain of muscle, fascia and tendon at neck level|
|Thoracic Sprain||847.1||S23.3xxA||Sprain of ligaments of thoracic spine|
|Thoracic Strain||847.1||S39.012A||Strain of muscle, fascia and tendon of lower back|
|Lumbar Sprain||847.2||S33.5xxA||Sprain of ligaments of lumbar spine|
|Lumbar Strain||847.2||S39.012A||Strain of muscle, fascia and tendon of lower back|
|Lumbosacral Sprain||846.0||S33.8xxA||Sprain of other parts of lumbar spine and pelvis|
|Lumbosacral Strain||846.0||S39.012A||Strain of muscle, fascia and tendon of lower back|
|Sacral Sprain||847.3||S33.8xxA||Sprain of other parts of lumbar spine and pelvis|
|Sacral Strain||847.3||S39.012A||Strain of muscle, fascia and tendon of lower back|
|Sacroiliac Sprain||846.1||S33.6xxA||Sprain of scroiliac joint|
|Sacroiliac Strain||846.1||S39.012A||Strain of muscle, fascia and tendon of lower back|