Coding Strategy

If the doctor does not circle a diagnosis, it may be up to you to find one.

Don’t let an incomplete superbill damage your chances of submitting an accurate claim. If the doctor in your office fails to indicate the ICD-9 code for the condition that he treated, you should read through his documentation to find which diagnoses you should report.

Open the Notes When You Have to — and Even When You Don’t

Suppose your physician hands you a superbill with the procedures circled and the diagnosis left blank.

You could ask the physician which diagnosis to report, or you could examine the documentation yourself. If your office has a policy that includes “coding by abstraction” by certified/qualified coders, then submitting charges based on what is supported (documented) in the note is appropriate, says Barbara J. Cobuzzi, MBA, CPC, CPCH,CPC-P, CENTC, CHCC, with CRN Healthcare Solutions in Tinton Falls, N.J. The physician should be signing off on these charges as part of your internal policy.

Some practices choose to review the documentation and compare it against any diagnoses recorded on the superbill, even when they aren’t required to. This ensures that the documentation matches the code selection every time.

When in Doubt, Confirm With the Physician

If you are new at coding diagnoses from the physician’s notes, you should doublecheck your code selections with the practitioners before submitting your claims.

“Until a coder feels comfortable with the ICD-9 books and the codes used more often in their office, it’s a good idea to run the choices by a clinician,” says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance with the Physician Services Division of UPMC in Pittsburgh. “You never want to give a patient a disease or symptom they don’t have  ” or one more severe (or less) than what they have. This is also beneficial to the physicians, as if you select unspecified codes a lot they may learn how to better document the patient’s condition into their notes.”

Tip: Make sure your office creates a policy in writing that spells out what you should do when you encounter a superbill with no diagnosis listed. Some physicians prefer that you ask them for information, while most others rely on their coders to select an accurate code.

Check the Notes for Clues

Consider this example of a situation in which the coder must fill in the gap when the doctor has not written a diagnosis on the patient’s superbill.

Example: The physician’s superbill shows a level-three office visit with a patient wearing a lumbar orthosis. It also shows a date of injury of three days prior to the date of service and is missing the diagnosis code.

First step: You refer to the dictation, which reads: “The patient is a 13-year-old female being evaluated as a consultation at the request of Dr. Jones for lumbar pain. The low back pain started on 12-9-09 when she did splits during cheerleading.” The physician completes the remaining history, review of systems (ROS), past family and social history (PFSH), and exam.

Moving down through the chart note, you see that the patient brought an MRI and x-ray with her, which demonstrated a hairline fracture to the patient’s third lumbar vertebra (L3).

Under a separate heading, the doctor has given his assessment, which states: Closed L3 fracture, benign.

Next step: You look up “fracture” in Vol. 2 of the ICD-9 book and the most specific body area listed is “vertebra, lumbar (closed),” which is 805.4 (Fracture of vertebral column without mention of spinal cord injury; lumbar, closed).

You turn to Vol. 1 and read the information under the “fracture of vertebral column” heading to check for exclusions and see that none apply in this case. You search under 805.4 to see if by chance the book lists codes for benign or traumatic fractures, which it does not.

In addition, ICD-9 does not instruct you to add a fifth digit to 805.4. Therefore, you know that 805.4 is the most accurate code for your doctor’s visit.

@ Part B Insider (Editor: Torrey Kim, CPC).

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

You’ll turn to a V code when your neurologist reports ‘no effects,’ however.

When your neurologist sees a patient who had a stroke, either recently or in the distant past, he may record a number of different conditions — which makes your job more difficult. If you remember a few guidelines, you’ll select the proper ICD-9 codes for every cerebrovascular accident (CVA) case your neurologist treats.

Get Specific With 2 CVA Diagnosis Codes

When your neurologist sees a patient who has had a stroke, or CVA, he may document multiple deficiencies, both new and lingering. When the patient presents with speech and language deficits you have two diagnosis codes to choose from.

To help both differentiate the etiology of speech and language deficits, and to add specificity to those deficits, ICD-9 2010 includes two cerebrovascular disease lateeffects codes: 438.13 (Late effects of cerebrovascular disease, speech and language deficits, dysarthria) and 438.14 (…, fluency disorder [stuttering]).

If you are not aware of the “combined” ICD-9 late effects codes often you might misreport the ICD-9 code(s) indicating that the patient has the active or ongoing condition, in this case a CVA, rather than reporting the compliant late effect code.

Example: Your neurologist sees a patient who suffered a stroke three years ago and has subsequent hemiplegia on her right (dominant) side. In this case, you may report 434.91 (Cerebral artery occlusion, unspecified, with cerebral infarction) and 342.91 (Hemiplegia, unspecified, affecting dominant side) in error as if the patient is actively being treated for a current occlusion and hemiplegia rather than reporting the correct combined late effects code, 438.21 (Late effect of cerebrovascular disease; Hemiplegia affecting dominant side), says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACSPM, CHCO, owner of MJH Consulting in Denver.

Change Your Late Effects Code Thinking for CVA

Coding for CVA patients is done somewhat differently than coding late effects from other conditions, such as a spinal cord injury from an accident.

Key: When reporting late effects of a stroke, you only need to use a single ICD-9 code to describe the late effects or manifestations of the CVA, rather than report two ICD-9 codes — one for the residual effect and one for the condition’s cause or as sometimes referenced as the etiology of the manifestation.

Codes describing late effects of stroke appear in a separate section of the ICD-9 manual (438). These codes, such as 438.11 (Late effects of cerebrovascular disease; aphasia) and 438.21 (… hemiplegia affecting dominant side), describe both the manifestation and the etiology of the condition.

Let Documentation Guide You on Active vs .Late Effects

“A late effect is any residual effect that ensues from the original injury and/or condition and can be coded as such at any time after the onset of the condition,” says Claudia Kernaghan, CPC, coder for Nevada Imaging Centers in Las Vegas.

Example: A patient may have a vertebral fracture and continue to have pain years after the fracture heals. Some late effects present early, while others might only become apparent months or years later.

Warning: Don’t confuse late effects with complications. A complication is typically associated with a difficulty or problem that occurs with a specific procedure (996.xx) and not a condition due to the original disease or injury.

To determine if a condition is a late effect, you should look in your neurologist’s documentation for keywords such as:

• due to — such as “pain in right hip due to fracture last year”
• following — such as “personality changes following a brain injury in 1996”
• as a result of — such as “hemiplegia as a result of CVA”
• residual effect — such as “arthritis that is a residual effect of previous hip fracture.”

Capture ‘No Effects’ With V12.54

There can be instances where a patient who suffered a CVA does not have any neurologic deficits present. Find out what to do in those cases by subscribing to the Neurology Coding Alert. Editor: Joshua Thines.

Sign up for the upcoming on-demand Webinar, 5 Steps to Optimize Your Office’s Coding & Billing Practices, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Get the specifics on eye irritation to find the most accurate diagnosis code.

The spring allergy snap will be here soon. Be prepared to treat and code eye irritations to recoup all your deserved reimbursement with this advice from the field.

Get Specific With 3 Key Conditions

For your claims to be processed successfully, you must report the most specific diagnosis code available for your patient’s eye irritation. Most patients you see with eye irritations will have one of three major conditions:

1. Blepharitis (373.0x): This is an inflammation of the eyelids, particularly at the lid margins, typically associated with a low-grade bacterial infection or a generalized skin condition, according to www.allaboutvision.com.

Blepharitis occurs in two forms: anterior and posterior blepharitis. The anterior type affects the outside front of the eyelid where the eyelashes are attached. The two most common causes are scalp dandruff and bacteria. Posterior blepharitis affects the inner eyelid and is caused by problems with the oil (meibomian) glands in the eyelid. Two skin disorders are the cause: acne rosacea and scalp dandruff, relates the All About Vision Web site.

Tip: Seventy percent of dry eye patients also have blepharitis. So don’t overlook coding for both conditions if both are present. A complete diagnostic picture will help the payer understand the medical necessity of the treatments chosen, which in turn will facilitate getting your claims paid.

2. Dry eye (375.15): This is caused by decreased production of fluids from tear glands, which destabilizes the natural tear film, allowing it to break down rapidly and create dry spots on the eye surface, according to www.mayoclinic.com. An imbalance in the substances that make up the tear film also causes dry eyes. Treatment of dry eye aims to restore a more normal tear film to minimize dryness, blurred vision, and discomfort.

3. Conjunctivitis (372.xx): Otherwise referred to as allergic disease or “pink eye,” this ailment is characterized by redness and inflammation of the membranes (conjunctiva) covering the whites of the eyes and the membranes on the inner part of the eyelids, according to www.medicinenet.com. These membranes react to a wide range of bacteria, viruses, allergy-provoking agents, irritants, and toxic agents, as well as to underlying diseases within the body. Viral and bacterial forms of conjunctivitis are common in childhood, but they can occur in people of any age, relates the Medicine Net Web site.

Consider Primary Reason for Visit Experts advise: If the primary diagnosis is a routine check-up and blepharitis or conjunctivitis is a secondary finding, the practice should still code for a routine visit.

Example: A new patient comes in for a routine eye exam. The ophthalmologist performs a comprehensive exam and discovers tear film insufficiency. Report 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits), and link it to V72.0 (Examination of eyes and vision). As a secondary diagnosis, report the dry eye with 375.15 (Tear film insufficiency, unspecified). If the primary reason for a new or subsequent visit is medical, then the office crosswalks to the minor evaluation and management (E/M) codes — 99201-99215 — leaving the 92000 codes behind. The E/M codes require specific levels of history, examination, and medical decision making, notes Raequell Duran, CPC, president of Practice Solutions, a coding, compliance, and reimbursement consulting firm based in Santa Barbara, Calif. The 920xx codes do not have those requirements, she explains.

Important: This means that you may need to focus on taking a more complete history to support submitting codes in the 99201-99215 range. You must also document the extent of your examination and the complexity of your medical decision making.

Example: A patient with chronic blepharitis (373.00, Blepharitis, unspecified) comes in due to a recent foreignbody sensation. During the history intake, the patient mentions a recurring headache (784.0, Headache). The patient had an unremarkable comprehensive exam four months ago, and you don’t think it’s necessary to do another dilated exam. A slit-lamp exam reveals a lash rubbing the cornea on the painful eye (930.0, Corneal foreign body). Refraction indicates a significant increase in hyperopia (367.0, Hypermetropia), which may explain the headache.

You can report an E/M code — as long as you meet the documentation guidelines for the E/M codes. Be sure to document the date of onset, frequency and duration of symptoms, level of discomfort, whether the condition is improving, and other details defined with the E/M codes that are not as specific with the eye codes. Many carriers will look for an E/M code if there is a medical diagnosis.

Keep in mind that an ophthalmologist may report either the eye codes (92002-92014) or the E/M codes (99201-99215) for any encounter as they see appropriate.

There are no hard and fast rules and only strong suggestions to report the eye codes vs. E/M codes, experts say.

@ Ophthalmology Coding Alert. Editor: Jerry Salley, CPC

Want to know more? Order the OPHTHALMOLOGY & OPTOMETRY CODING LIBRARY.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Assigning an ICD-9 code merely to get your claim paid could land you in legal hot water.

Medical coders face a lot of questions each day in the course of their work, but one question you should not be asking is “which diagnosis code should I put on this claim if I want to collect?”

When the Insider solicited subscribers’ questions last week, the overwhelming majority asked questions such as, “We performed xyz procedure — can you tell me which diagnosis codes we can report to Medicare to get this claim paid?”

But this type of ICD-9 coding is backward, experts say. Instead, you should be coding based on the documentation — not based on which codes your MAC will reimburse.

“I do not feel that we as coders should be coding based on getting the claim paid,” says Michelle Jubeck, CPC, CEMC, CPMA, coding compliance analyst with Monroe Clinic in Monroe, Wis.

Jubeck points to the ICD-9-CM guidelines, which state, “The entire record should be reviewed to determine the specific reason for the encounter and conditions treated.”

Keep in mind: “It is illegal to just assign an ICD-9 code that will get your claim paid — you have to report the codes documented in the record,” says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. Any diagnosis that you report on a claim must be clearly documented in the patient’s chart — not selected because it’s a covered diagnosis.

ABN use: “If you want to know what will justify the medical necessity of the service the physician performed so you know when to get an advance beneficiary notice (ABN) signed, you need to look at your local coverage decisions (LCDs),” Cobuzzi says.

Tip: In some cases, an LCD will list a very general or unspecified diagnosis code as being payable, whereas your physician has documented a more specific diagnosis which isn’t in the LCD. “In these cases, you should still report the documented diagnosis, but if the MAC denies the claim, appeal it by saying ‘If the unspecified code is payable, then why isn’t the more specific condition considered medically necessary?’” Cobuzzi advises.

Bottom line: “We need to have a good rapport with our physicians — let them know that documentation (accurate and complete) begins and ends with them,” Jubeck says.

@ Part B Insider

Be a hero. Join the coding community at the Supercoder Fan Page.

Related articles:

1. What’s the Correct Diagnosis Code for a Urine Drug Test?Question: What is the proper ICD-9 code when the lab...
2. 3 Pulmonary Diagnosis Coding TipsRemember to focus on acute conditions & exacerbations. Correctly reporting...
3. Dx Coding Moves That Stop Denials for Chronic Pain ClaimsTip: Code prior conditions in these cases. Imagine your pain...

Tip: Time-based E/M might be in line when managing diabetes, asthma, ADHD.

Overlooking time as the key factor on a camp or sports exam in which the patient has a problem could cut $30 per claim.

Opportunity: An office visit (99201-99215, Office or Other Outpatient Services) using time as the key factor might be appropriate, but keep in mind that lowballing time-based E/M codes because of poor documentation can be a revenue-loser for many practices, says Jennifer Godreau, who’s presenting a free webinar next week to help coders tackle trouble-spots.

Watch for Chronic Conditions

“If there is a chronic medical problem to update, e.g. asthma, we often use that diagnosis code (such as 493.00, Extrinsic asthma; unspecified) and code by time, as counseling will often be more than 50 percent of the visit time,” says Marc Tanenbaum, MD, FAAP, a pediatrician with Pediatrics and Adolescent Medicine in Atlanta.

The patient’s health problem might affect his ability to participate in a certain camp activity or type of camp. “I’d want to do a more recent assessment and some updated counseling regarding the patient’s health issue and how to handle any potential problems that might arise at the camp,” notes Nancy Bishoff, MD, FAAP, a private practice pediatrician in Lexington, Ky.

Be Alert to Counseling Time

When coding based on time, careful complete documentation of the time elements is a must, including total face-to-face time, and minutes spent counseling and/or coordinating care. Also include a brief sentence related to the general areas discussed during the time.

Check out how the key components of history, examination, and medical decision making (HEM) versus time measures up in this example: A teenage boy with benign hypertension (401.1, Essential hypertension; benign) wants to attend survival camp. The pediatrician performs an expanded problem focused history, an expanded problem focused examination, and low complexity medical decision making, which qualifies as 99213 based on HEM. The pediatrician documents she spends 15 minutes counseling the patient on hypertension management and the visit lasts 25 minutes.

Because counseling comprises the majority of the encounter’s total face-to-face time, you can code the visit using time as the controlling factor and select 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity … Physicians typically spend 25 minutes face-to-face with the patient and/or family). If you had overlooked this fact and instead coded 99213 based on HEM, you would have sacrificed approximately $31* in pay.

*Note: The 2009 Medicare Physician Fee Schedule, which you can use as a benchmark to judge private payers’ fees, assigns 2.56 relative value units to 99214.

Using the conversion factor of 36.0666, 99214 pays approximately $92. Code 99213 has 1.70 RVUS, which equates to approximately $61.

Heads Up on Other Disorders, Diseases

Some other examples of chronic conditions that might warrant an updated history, exam, and counseling are diabetes (for instance 250.01, Diabetes mellitus without mention of complication; type 1 [juvenile type], not stated as uncontrolled) and ADHD (314.01, Hyperkinetic syndrome of childhood; attention deficit disorder; with hyperactivity).

@ Pediatric Coding Alert

Can’t wait for Jen’s free webinar to start your search for lost cash? Go to Supercoder.com, and get the latest expert advice.

Be a hero. Join the discussion at the Supercoder Facebook Fan Page.

Related articles:

1. Counseling Must Dominate Exception Claims For Seamless PaymentChoose the service level using the documented history, exam, and...
2. Mid-Level E/M Coding BreakdownOur chart shows you how to choose among 99212, 99213 &...
3. E/M Challenge: Can I Report 99214 and +99354?Counseling representing more than 50 percent of E/M visit? Choose...