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.

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Discover why coding a myofascial flap twice is a big mistake.

Question: Our surgeon performs an abdominal closure using left and right myofascial advancement flaps. I believe we should code one unit of 15734 because flap codes refer to the recipient area — not donor site. But the surgeon believes we should code 15734 x 2 because he uses two flaps to perform the defect closure. What is the correct coding?

Arkansas Subscriber

Answer: You should not report 15734 (Muscle, myocutaneous, or fasciocutaneous flap; trunk) for this service — either once or twice. Instead, you should list the procedure using an adjacent tissue transfer code such as 14000 (Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less) or 14001 (… defect 10.1 sq cm to 30.0 sq cm) depending on the defect size.

Here’s why: Adjacent tissue transfer rearrangement includes repair by advancement flaps, according to CPT instruction in the introduction to those codes. On the other hand, 15734 does not specifically include myofascial flaps and does not describe advancement flaps for closure.

Size matters: Rather than coding this twice, you should code the entire size of the primary and secondary defects (including secondary defects for both flaps). If the defect is larger than 30.0 cm, you can still use the adjacent tissue transfer or rearrangement codes by listing 14301 (Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm) and adding +14302 (… each additional 30.0 sq cm, or part therof [list separately in addition to code for primary procedure]) as needed.

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What your pulmonologist writes in the documentation matters.

The pulmonologist’s documentation, along with the patient’s medical record can make or break your chronic obstructive pulmonary disease (COPD) reporting. One key is making sure that your coding accurately identifies the patient’s specific pulmonary condition and any other associated acute condition (if necessary).

Background: According to the National Heart Lung and Blood Institute, COPD is a serious lung disease that, over time, makes it hard to breathe. In people who have COPD, the airways — the bronchial tubes through which air moves in and out of your lungs — are partially blocked, which makes it more difficult to get air out than in.

These hints will help you determine which ICD-9 codes you should report when the patient has other conditions that are related to COPD.

Hint 1: Category 493 Fits COPD and Asthma

Asthma is a disease distinct from COPD. However, the two may co-exist in the same patient. The ICD-9 493 category includes all the asthma codes you might need. If your pulmonologist diagnoses COPD and asthma together, look to the terms he uses in the medical record and use them as your guide to select which code to report.

The asthma codes you’ll choose from are:

• 493.20 — Chronic obstructive asthma, unspecified
• 493.21 — Chronic obstructive asthma with status asthmaticus
• 493.22 — Chronic obstructive asthma with acute exacerbation.

Heads up: You might find some confusion about selecting 493.20, a less-specific code. You should clarify with the pulmonologist if the patient has status asthmaticus or an acute exacerbation before opting to go for the “default” code. If the patient does not have either of these two conditions, only then should you use 493.20. Underdocumented details may affect the most specific ICD-9 code selection.

Additionally, if your pulmonologist documents status asthmaticus with any type of COPD, you should list that diagnosis first. The status asthmaticus diagnosis “supercedes any type of COPD, including that with acute bronchitis or acute exacerbation,” says Deborah J Grider, CMA, CPC, CPC-H, CPC-P, CCS-P, CCP, EMS, president of Indianapolis-based Medical Professionals Inc and author of the American Medical Association’s Principles of ICD-9-CM Coding. You should only assign the fifth digit of “1″ in this case (493.21), not the fifth digit of “2″ (493.22).

Hint 2: COPD + Bronchitis = 491.2x

Chronic obstructive bronchitis is a more specific diagnosis than the non-specific term, COPD (496). If your pulmonologist documents chronic obstructive bronchitis in a patient, you should bill 491.2x (Obstructive chronic bronchitis: 0 without exacerbation, 1 with (acute) exacerbation and 2 with acute bronchitis).

Note: The CPT code 466.0 (Acute bronchitis) is no longer necessary to report in the setting of chronic obstructive bronchitis since the descriptor for 491.2x already mentions “acute bronchitis.”

It is possible that the pulmonologist would document that a patient is having acute bronchitis with COPD which is causing an acute exacerbation. When faced with this scenario, remember that the acute bronchitis causes the exacerbation, thus you should still report 491.22 (Obstructive chronic bronchitis with acute bronchitis), says Alan L Plummer, MD, professor of medicine in the division of pulmonary, allergy, and critical care at the Emory University School of Medicine in Atlanta, Georgia.

On the other hand, if the documentation states that the patient has COPD with acute exacerbation, but doesn’t mention acute bronchitis, report 491.21 (Obstructive chronic bronchitis, with [acute] exacerbation).

Example: A patient with COPD who is not well-controlled is just using an albuterol inhaler. The pulmonologist decides to add a steroid inhaler to current therapy along with a long-acting beta-2 agonist. You could report the encounter using only 496 (Chronic airway obstruction, not elsewhere classified), but a more descriptive code would be 491.21. This code specifically identifies the patient as having chronic obstructive bronchitis and indicates that the patient’s clinical problems are not controlled.

Important: If the diagnoses states only COPD, with no other manifestation or condition associated with it (i.e., chronic bronchitis or emphysema), you should opt for 496. If the patient has emphysema in addition to chronic obstructive bronchitis, you should also code 491.2x since this code also includes emphysema. If the patient does not have chronic bronchitis but does have emphysema, you should code 492.8 (Other emphysema).

Hint 3: Documentation Must Jive With COPD Diagnosis

If you’re going to list a COPD diagnosis code, be sure the documentation supports the physician’s code selection. You should look out for details in the documentation, such as a listing of signs, symptoms and conditions. Play it safe by having enough detail in the history of present illness and the review of systems to support a diagnosis of COPD.

Watch for: Your pulmonologist should also document the tests he orders, such as X-rays (71010-71035), and pulmonary function tests (94010-94621). Document any therapeutic drug treatment associated with the plan of care for the patient. The tests and treatments help support your physician’s diagnosis of COPD.

Don’t miss Jennifer Godreau’s audio: “Ten Tips for Improve Your Pulmonology/Critical Care Coding Right Now.”

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