# Change Diagnosis; when is it fraud



## svms (Apr 14, 2014)

Hi,

My question is I have a claim that denied for medical necessity? 

The diagnosis the Dr. used is 716.96 (knee arthritis)-an unspecified arthritis code; but the only covered diagnosis is 715.16, 715.36, 715.96 (Osteoarthrosis-knee) which is a more specific code.

Would it be okay to query the Dr. and have him addend the office note if his documentation substantiates a covered diagnosis, OR IS THIS FRAUD?

I am not exactly sure what the definition of fraud is with a diagnosis change and don't want to get myself in trouble here.

Also, can someone lead me to a link that tells me when we can change a diagnosis and when it is not allowed. 

Thanks


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## mitchellde (Apr 14, 2014)

You cannot amend a note after a claim is submitted.  If you could then everybody would amend the note to add better information for appeals.


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## mitchellde (Apr 14, 2014)

The dx code you use must match the providers written diagnosis.  Therefore you can change the diagnosis code if the documentation is there but you cannot document more to try to obtain a better dx code.


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## svms (Apr 16, 2014)

Thanks Debra,

This is my situation...

The doctors office I work at uses electronic medical record and they are the one that chooses the diagnosis code. I evaluate the medical documentation to make sure that it substantiates the code they select.

My circumstance at the present is I already sent the claim out the door. It is for J7323 Euflexxa and as mentioned above the diagnosis the Dr. used is 716.96 (knee arthritis)-an unspecified arthritis code; 

THE ONLY COVERED DIAGNOSIS FOR J7323 IS 715.16, 715.36, 715.96 (Osteoarthrosis-knee) which is a more specific code.

If my doctor would have used a diagnosis such as knee pain, I would just write off because it is specifically a noncovered diagnosis.

But my direct question is the diagnosis he used is very close to the covered diagnosis..a nonspecific arthritis code [716.96]. CAN I GO TO MY DOCTOR TO REVIEW THE DOCUMENTATION TO SEE IF PERHAPS THE FINAL DIAGNOSIS MAY BE THIS SPECIFIC ARTHRITIS CODE THAT IS COVERED?? I do not want to ask the physician to do anything that is not allowed so I am wanting to know where the fine-line lays in changing a diagnosis before it actually becomes fraud.

Is there a link or can you direct me to someplace that does have the guidelines to changing a diagnosis.

Thanks,


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## mitchellde (Apr 16, 2014)

The document must speak for itself.  The time to review the documentation is befor the claim is submitted.  Many times providers code based on cheat sheets which is a minimal choice list of codes.  They are not coders!  The coder must review the documentation, then if there is insufficient information for a specific code the provider can be requested to provide additional information.  Unspecified codes should be used only in rare instances however they are overused.  Just because the diagnosis is close does not mean you can query for additional information due to a denial.  However if the documentation is more specific you can change the code.  The code on the claim does not need to match the code the provider selects but it must match the documentation.  This is documented in a regulation, however it was years ago you will need to research the internet, maybe the OIG site or CMS.  
So in summary, once the claim has been submitted you cannot change the documentation however you can correct the code to match the original documentation if the wrong code was selected.


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## svms (Apr 16, 2014)

Thanks Debra,
Greatly appreciation the information you shared.


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## admiller04@gmail.com (Jun 4, 2014)

If the physician documents an unspecified diagnosis in his dictation for that days evaluation and management service, can a coder review pathology, radiaology or other documents located within the patients medical record needed in order to code to the highest specificity? CMS requires codes to be coded to the highest specificity so I'm asking if a coder is allowed to review these types of documents to achieve that....?


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