The ICD-9CM coding was established in 1956 by the World Health Organization as a way of standardizing the collection of data necessary to recognize and respond to outbreaks of disease (ICD-10 coding will be even more specific).
Since that time, diagnosis coding has become much more important; now, it can affect your wallet.
Insurance carriers store the information collected on patients in a national databank which is used by insurance companies to assess the insurability of individuals or groups (like pre-existing conditions).
Insurance carriers also use these codes to ascertain whether the care rendered is appropriate. This boils down to… “if you don’t code properly you won’t be paid properly (or at all!).”
More than 92% of the claims submitted by physician offices are “unclean”, meaning one or more items are missing or incorrect on a claim. It is the duty of an insurance carrier to pay all clean claims on behalf of their insured. They don’t have to pay incorrect claims. The only reason they let the other 90+ percent go through is that it costs them money and time to deny a claim and then reprocess it. It also angers the insured if his claims aren’t being paid. Insurance carriers fix or ignore a lot of your mistakes just to keep the wheels turning.
As insurance carriers tighten up the available health care dollars, they are going to insist on clean claims. Get yourself and your staff on the right road now to avoid problems in the future.
- Assuming a working knowledge of diagnosis coding, here are some things to remember:
- Your primary diagnosis should be “what brings the patient in for treatment today.”
- NOT what is the most “serious” thing wrong with the patient.
- NOT what other things might be wrong with the patient at the same time.
- NOT what was wrong when the patient first came to your office.
NEVER use *RULE-OUT as a diagnosis – (see “incorrect coding”, below).
- Your secondary diagnoses should include:
- Complicating factors – if they affect your medical decision-making process.
- Manifestations – if they are the result of the primary diagnosis and affect treatment or decision-making. (i.e., fatigue, weight loss, etc.)
- Co-existing conditions – if they affect treatment or decision-making.
♦ All diagnoses should be coded to the most specific code possible. Look over the claims forms being sent out of your office. If a majority of the diagnosis codes end in “.9″, you are guilty of lazy coding. This is especially dangerous to specialists, as they are paid to be more precise.
♦ Signs and symptoms (codes 780-799) should only be used in the absence of a definitive diagnosis.
♦ Lab work may not use the same diagnoses as your evaluation and management services.
♦ Be certain that your diagnoses substantiate the need for performing the services that you submit. This is known as diagnostic relevancy.
♦ Always use current code books and resources. Codes change annually (and a few here and there more often). If you are using an old code you may not get paid.
♦ Be sure that your medical billing software allows for multiple diagnoses per procedure line. (The HIPAA electronic transaction standards version 4010 allows 8 dx and the 5010 will allow 12)
♦ Incorrect coding can affect the ability of the patient to obtain health insurance. You can be legally liable if you cause the patient to be uninsurable! (i.e., an incorrect diagnosis of AIDS, using *rule-outs, etc.)
As insurance claim processing continues to become more automated, fewer claims are going to be corrected by human clerks. Incorrect claims will be returned to your office for correction (denied!). This costs MUCH more time and money than doing it right in the first place.
Invest in training for you and your office staff. The time and money spent on training now will reap big rewards in the future.
The survivors of the “coding game” will be the ones that do it right. The casualties will either be compelled to get out of medicine or forced to settle for increasingly smaller reimbursements.
Which one will you be?
