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Reviewing the fundamentals can strengthen your ICD-9 coding and streamline thereimbursement process.
Fam Pract Manag. 1999 Jul-Aug;6(7):27-31.
When you talk about the work you do and the conditions you see, you usewords — patient visit, suture, Pap smear, sinusitis. When third-partypayers refer to the work you do and the conditions you see, they usenumbers. Almost every medical condition, service and supply can beidentified by a numeric code, primarily because Medicare and otherthird-party payers require numeric coding on claim forms. They set thepayment rules, so they also get to establish the system's “vocabulary.”
Being fluent in the language of coding may not be every doctor's dream.
But accurate coding is the key to prompt reimbursement for your services.
It's helpful even in environments dominated by managed care, giving you a database you can use in practiceprofiling and contract negotiations. In addition, the codes you submit are used by the federal government to ferretout health care fraud. So knowing the difference between a diagnosis code of 280 (iron deficiency anemia) and820 (a fracture of the neck of the femur) will help protect your practice from fraud and abuse investigations, aswell as help ensure that you get paid for what you do. Consequently, it's more important than ever that you take amoment to brush up your coding skills and improve your coding accuracy.
Elsewhere in this issue, you'll find a tool to help you choose the right CPT code for more-involved evaluation andmanagement services (see “A Quick-Reference Card for Identifying Level-4 Visits”). In this article, you'll get arefresher in the language of coding symptoms and diagnoses.
Reimbursement claims actually require the use of two coding systems: one that identifies the patient's disease orphysical state (the International Classification of Diseases, 9th Revision, Clinical Modification, or ICD-9-CM,codes) and another that describes the procedures, services or supplies you provide to your patients (the CurrentProcedural Terminology, or CPT, codes). To differentiate between these coding systems, think of it this way: CPTcodes describe what you do, and ICD-9 codes describe why you do it.
Each service you provide becomes a line item (a CPT code) on an insurance claim form. Although your level ofreimbursement is linked to a claim's CPT codes, you need to record a symptom, diagnosis or complaint (an ICD-9code) to establish the “medical necessity” of each service. Showing medical necessity basically means that youjustify your treatment choice (CPT code) by linking it to an appropriate diagnosis, symptom or complaint (ICD-9code). Up to four ICD-9 codes can be linked to each CPT code on a HCFA-1500 form.
For example, a patient in the office for routine diabetes monitoring also complains of chest pain suggesting angina
pectoris. As part of the work-up that day, you perform an ECG in your office. On your claim form, however, youlist only the ICD-9 code for diabetes. In all likelihood, the insurer won't pay for the ECG because it's not clearfrom the claim form why the test was medically necessary. The ICD-9 code for chest pain or angina pectorisshould also have been listed to indicate the medical necessity for the ECG.
Code to the highest degree of specificity. Carry the code to the fourth or fifth digit when possible.
Link the diagnosis code (ICD-9) to the service code (CPT) on the insurance claim form to identify why theservice was rendered, thereby establishing medical necessity.
“Ruled out,” “suspected,” and “probable” diagnoses cannot be coded. Assign the applicable code for thesign or symptom that is the reason for the patient visit.
Code the primary diagnosis first, followed by the secondary, tertiary, etc., diagnoses. The primarydiagnosis is the main reason for the patient visit.
Code coexisting conditions that affect the patient's treatment in that visit. Code chronic conditions whenthey apply to the patient's treatment. Don't code diagnoses that are no longer being treated or that don'taffect your care of the patient.
ICD-9 codes are organized in three “volumes,” which aren't necessarily separate publications, and are available ina variety of print and electronic formats (the codes themselves are in the public domain). Volume I is a numericlisting of the roughly 12,000 diagnostic codes and descriptions (give or take a few!). Volume II is an alphabeticindex of terms and the codes that correspond to them; its more than 120,000 entries direct you to the codes youneed by linking them to a variety of terms. Volume III contains a tabular list and alphabetic index of proceduralcodes and descriptions and is intended for use only by hospitals. Always look in the index first and then turn tothe numeric listing for a complete description of the condition. Never code solely from the index.
ICD-9 codes may have three to five digits depending on their category (although only a few diagnoses have validthree-digit codes). Each digit provides important information about the patient's condition. For example, considerthe following codes in the diabetes mellitus category:
250.13, uncontrolled type 1 diabetes with ketoacidosis.
The three-digit code (in this case, 250) represents the diagnostic category. The fourth digit identifiescomplications associated with diabetes (e.g., ketoacidosis). The fifth digit describes the type of diabetes and itslevel of control. To correctly code an encounter with a patient who has uncontrolled type 1 diabetes complicatedby ketoacidosis, you should use all five digits.
Here's another example: You see a patient for follow-up of benign essential hypertension. The proper code wouldbe 401.1 The fourth digit identifies the disease as benign and thus is the most specific description of your patient'scondition. If, however, the patient also had benign hypertensive heart disease, then you would include a fifth digit:The proper code would be 402.10 or 402.11 depending on the absence or presence, respectively, of congestiveheart failure.
The point is that you must always code to the highest number of digits that best describe your patient's condition.
To be certain you're using the correct number of digits, review the codes in a given category and choose thehighest-level code that most specifically describes your patient's condition. Many payers, including Medicare, will
deny or delay payments if you fail to do so.
A useful tool for ICD-9 coding is Family Practice Management's “ICD-9 Codes for Family Practice,” compiledby Allen Daugird, MD, MBA, and Donald Spencer, MD, MBA, of the Department of Family Medicine,University of North Carolina. The list includes many of the ICD-9 codes family physicians use most often,organized alphabetically within categories of diseases and body systems. A version of the list printed oncardstock, designed to be carried with you as you see patients or to be placed in each exam room, isavailable from the AAFP Order Department at 800-944-0000. Ask for item number A512 (for two copies) orA513 (for 10 copies).
For more information on ICD-9 coding, review these articles from the FPM archives:
“An Easy Reference to ICD-9 Codes.” A. Daugird, D. Spencer. October 1996:41–44.
“Use New Diagnosis Codes to Avoid Claim Denials.” K.J. Moore. October 1998:15–16.
In addition, watch for an ICD-9 update this fall in FPM, once the code changes for 1999-2000 are announced.
Choosing the most specific code means coding only what you know to be a fact. Patients often have ill-definedcomplaints, such as back pain. While you may suspect a specific condition —perhaps a herniated disc or aurinary tract infection — and then order lab tests to confirm the diagnosis, you should code only the sign orsymptom that brought the patient in to see you until you receive the test results or otherwise make a definitivediagnosis. (See “ICD-9 coding challenges” for an example.) If you don't, you may inadvertently label the patientwith an incorrect diagnosis and, as a result, the patient may have difficulty obtaining health and disabilityinsurance or may end up paying higher insurance premiums in the future.
Use ICD-9 codes 780 to 789 to describe symptoms, signs and ill-defined conditions that aren't linked to a specificdisease. But be aware that some body-system categories of codes include codes for nonspecific conditions. Forexample, the code for a breast lump is found in Volume I under “Genitourinary System,” in the subcategory “Signsand symptoms in breast,” and would be properly coded as 611.72, “Lump or mass in breast.” Use these codes(rather than codes for more specific disorders) when the only facts you have are the patient's signs and symptoms.
When you need to list more than one diagnosis for your patient, prioritize them: Code the primary diagnosis firstfollowed by the next most important and so on. The primary diagnosis should be the one that receives the mostattention during the patient visit. For example, if a patient you're treating for hypertension presents with an upperrespiratory infection, the infection would be considered the primary reason for the visit and should be listed first,followed by hypertension.
Patients with multiple diagnoses can pose quite a challenge (again, see “ICD-9 coding challenges” for anexample). For example, you're treating a patient with poorly controlled diabetes, hypertension and coronary arterydisease. Because you see the patient most often for blood-glucose monitoring, the primary diagnosis would bediabetes followed by hypertension and coronary artery disease (unless the patient had active signs or symptomsrelated to one of the other conditions). And here's a related tip: Don't code a diagnosis that doesn't affect yourcare of the patient. For example, if your patient with diabetes is also being treated by an orthopedist for a brokenarm, don't code the fracture since it doesn't affect the care you're providing.
You may submit up to four diagnoses on a HCFA-1500 form, and (as noted above) you may link up to fourdiagnosis codes to each CPT code. But remember that some payers will read only the first ICD-9 code linked to
the CPT code, so it's important to prioritize and link the ICD-9 codes accurately.
Evaluate your coding skills by choosing the correct ICD-9 code(s) for the following two patient visits. Theanswers and explanations appear below.
A patient complains of epigastric pain. You suspect reflux esophagitis and order an upper GI series.
What ICD-9 code(s) would you submit for this visit?
A female patient complains of dysuria and increased frequency. A microscopic exam performed in youroffice reveals the presence of bacteriuria, and you order a culture. During the visit, the patient also asksyou for a refill of Synthroid. Reviewing her medical history, you notice that she has not had her thyroidlevel checked in some time, and you perform a thyroid-stimulating hormone test. Assuming that thispatient has Graves' disease, what ICD-9 code(s) would you submit for this visit?
For case 1, the correct code is 789.06 for “Abdominal pain, epigastric.” Although you may suspect refluxesophagitis (530.11), you can't make a definitive diagnosis until you receive the test results. Therefore,you must code only the symptoms. (Remember: Code only what you know.) Since proper codingrequires use of the highest number of digits that best describe your patient's condition, you must use fivedigits here. The fifth digit describes the location of the pain. Avoid using a “default” fifth digit such as “0”to describe an unspecified site as it may cause some third-party payers to question the medicalnecessity.
For case 2, the answer is less straightforward; this visit may be coded several ways. You could choosecode 788.1 for the dysuria and code 788.41 for the frequency. These symptoms would support the needfor the office visit, microscopic exam and the subsequent culture. Since bacteriuria was present onexamination, a definitive diagnosis (cystitis) was actually made at the time of the patient visit.
Consequently, the visit and the tests could also be correctly coded as 595.0 (acute cystitis).
According to instructions in ICD-9-CM, the organism should also be coded; however, since you don'thave the results of the culture, you can't yet identify the specific organism involved. Hence, 595.0 wouldbe acceptable to most insurers. One could argue that this code shouldn't be used to support themicroscopic exam because the symptoms, not the diagnosis, were the reason for performing it.
Next, you'll need to code the hyperthyroidism. The correct category is 242, “Thyrotoxicosis with orwithout goiter.” There are several choices under this heading. But since the patient has Graves' disease,the code 242.00 (“Toxic diffuse goiter without mention of thyrotoxic crisis or storm”) most accuratelydescribes the patient's condition.
Finally, you must properly link the ICD-9 codes to each of the services provided. The primary reason forthe visit is the dysuria and frequency. List these codes first, and link them to CPT codes for the two testsfor the urinary complaints. The hyperthyroidism code should not be linked to the urinary tests. Link code242.00 only to the thyroid-stimulating hormone test.
No matter who actually does the coding in your practice, the physicians are legally responsible for the codes
selected and submitted to payers. Since it's usually the physicians who have first-hand knowledge of whatoccurred during the patient visit, the initial code selection should come from them. Office staff can providevaluable help with the nuances of coding and specific payer requirements. Working as a team, physicians and staffcan ensure that coding is done properly.
Coding will never be the part of your work that you enjoy most; if it were, you wouldn't have bothered withmedical school. But you do need to know the basics and be able to speak the language of coding. Why? Thebottom line is your bottom line: Accurate coding of diagnoses, signs and symptoms helps to streamline paymentfrom third-party payers. Although the coding system may seem confusing at first, it becomes an importantmanagement tool — once you get used to it.
Emily Hill is president of Hill & Associates Inc. in Wilmington, N.C.
Copyright 1999 by the American Academy of Family Physicians.
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