Traumatic Subluxation Coding Controversy

February 1st, 2018 - Wyn Staheli, Director of Research

Categories: Chiropractic Diagnosis Coding Compliance

There has been some controversy over the use of the ICD-10-CM subluxation codes commonly referred to as traumatic (S13.1-, S23.1-, and S33.1-). Are they appropriate for chiropractors to use? The answer to that question is complicated. The problem basically lies in the lack of official guidance and differing opinions on what the word “subluxation” means. The official description for those categories states “Subluxation and dislocation of” along with the associated location. According to the ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.14, when the word ‘and’ appears in the title, it is to be interpreted as meaning either “and” or “or”. Therefore, based upon these guidelines, it would be appropriate to read the description as “subluxation of.” However, there are those who assert that subluxation in this context refers to an allopathic subluxation which is not the same thing as a vertebral subluxation (also known as the chiropractic or nonallopathic subluxation) and therefore are contraindicated for CMT.

The 2018 ChiroCode DeskBook, page 269, lists several reasons why these codes might not be appropriate for reporting with CMT and states, “For these reasons, it appears that the injury codes (S13.1-, S23.1-, and S33.1-) are not really ideal for the chiropractic definition of a subluxation; nonetheless they are fine if the provider is trying to describe a partial dislocation which may need to be immobilized rather than manipulated.” This would occur more commonly in a personal injury or workers compensation situation.

According to WHO guidelines published in 2005, the medical definition of a subluxation “is a significant structural displacement, and therefore visible on static imaging studies.” Thus, it could be inferred that their intent with the word subluxation for these codes (which are not mentioned in this document) is more descriptive of a dislocation and not a vertebral subluxation. However, it is not specifically stated so it leaves it open to interpretation.

While all this points to NOT reporting these codes with CMT, the controversy continues with a review of Aetna’s Chiropractic Services Policy which includes the following listing of covered diagnosis codes: S13.0- to S13.9-, S23.0- to S23.9-, and S33.0- to S33.9-. However, the policy is silent about whether these codes are appropriate to use to justify CMT procedures.

At this time, whether or not you use these codes is really based on the clinical presentation and payer policy as there is no CLEAR guidance from HHS as to the true definition of a subluxation in the context of these codes. Is it fraud to use them? No, as long you are meeting payer definitions and guidelines. For example, for Medicare, it is clear that they view a vertebral subluxation as indicative of the M99.0- and M99.1- codes and thus the S13.1-, S23.1-, and S33.1- codes should NOT be used in conjunction with CMT; however, they could be appropriate (but not payable) to report with other procedures. Proper documentation is also necessary, if using these “injury” subluxation codes. Exam findings must also include documentation of the specific vertebral space along with the extent and type of the injury (dislocation or subluxation).

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