Coding with Confidence (101)
June 29, 2016
As billing professionals know, to code with confidence is to code to the highest level of specificity. With the new verbiage available to us via the expanded codes in the ICD-10 system, we can paint a picture of our patient with numbers. But how best to accomplish this?
First, know the basics well:
An ICD-10-CM diagnosis code, built on categories for diseases, injuries, and symptoms, has between three and seven alphanumeric characters. A category code has three characters. Most categories have subcategories of either four-character or five-character codes. Valid codes can be three to seven characters in length, depending on the number of subcategories provided. This variable structure enables coders to assign the most specific diagnosis that is documented in the patient medical record.
There are many more categories for disease and other health-related conditions, and much greater flexibility for adding new codes in the future. ICD-10 is a larger code set, having about 69,000 codes versus ICD-9-CM's approximately 13,000 codes. ICD-10-CM also offers a higher level of specificity and additional characters and extensions for expanded detail. In addition, there are many more codes that combine etiology (cause) and manifestations, poisoning and external cause, or diagnosis and symptoms.
Now let’s add subcategories:
When they are available for assignment in the code set, sixth and seventh characters are not optional; they must be used. CMS rules state that a claim can be rejected when the most specific code available is not used. It’s important to keep in mind, however, that the coder can only code what is documented and cannot add to any statement in the medical record. Only the physician or health care provider can add to the statement in the medical record to clarify for coding purposes. That’s why communication between healthcare professionals is of paramount importance.
A few pointers:
Make these initiatives part of your daily routine: Assign codes to highest level of specificity. Code chronic conditions as often as applicable. Code all documented conditions that coexist at the time of the visit that require or affect patient care or treatment. Do not code conditions that no longer exist. Provide codes that have the highest degree of accuracy and completeness or the greatest specificity.
Think precision when you code:
The highest level of specificity should be given when establishing a diagnosis. What kinds of specifics are needed? Sites of injuries, infections, how the injury happened, specifics to rule out if another party is responsible for your claim, and more. If you code a fracture or injury without telling the insurance company the specifics, your claim could be held up for accident details from the member. If your patient fell out of bed at his or her home, use those ICD-10 codes specifically so the insurance company knows the story and will not hold up your claim for those details. Document all conditions that coexist at the time of the visit that require or affect patient care, treatment or management.
What can’t you code?
“Suspected or Rule Out” diagnoses cannot be coded. Conditions that were previously treated and no longer exist should not be coded. Also, ensure that your codes don’t contradict. For example, you can’t use codes with and without myelopathy.
Focus on telling the story.
Is it really only back pain? Unspecified can cause lower level of payment or denial. Is it degenerative or not? Not all people have back pain from getting older; discs may collapse or stiffness of osteoarthritis can happen -- all variables that can change the code. All diseases should be coded to most specifically illustrate your story. Spell it out for the insurance company! Leave no detail out, and don’t give them reasons to ask questions. Has your patient had a previous surgery? If you document the chart by writing details, it should also code by what’s in writing. Every patient has a different story to tell. Tell that story to the insurance company in the ICD-10 codes.
Who Can Provide Codes?
- Patient complaint or how patient describes symptoms (exactly quoted as the patient describes it) - Can be noted by nurse, or physician, or physician extender.
- The practitioner’s exam findings (physical and /or visuals, such as scars from a previous surgery) - Must be documented by physician only.
- Any diagnostic testing (CT, MRI, EMG, etc ) - Can be noted by physician or results may be in chart.
- Surgeon diagnosis based on all of above - Must be documented by physician.
