Fifth Digit Coding Critical to Optimize Reimbursement for MIs
Published on Thu Oct 01, 1998
When coding for category 410 (Acute Myocardial Infarction) adding the fifth digit is vital to getting adequately reimbursed. Keeping track of the standard eight week treatment period is important, too. The fifth digit is a subclassification indicator and, for MIs, represents the episode of care. If you dont note it correctly, Medicare and third party payers will deny payment, stresses Susan Garrison, MPC, CPC, CPC-H, CPAR, president-elect of the American Academy of Professional Coders and senior manager at Hyatt, Imler, Ott, and Blount, a coding and billing consulting firm in Atlanta.
Coding to the highest possible degree of specificity helps expedite prompt payment because it decreases unprocessable denials, she says.
Understanding ICD-9 Classifications
Categories are three-digit codes that represent a group of conditions or a related condition. For example, category 410 is acute myocardial infarction, which includes an embolism, occlusion, rupture, or thrombosis of the coronary artery, as well as an infarction or rupture of the heart, myocardium, or ventricle.
Subcategories are four digit codes that provide more information such as the cause or site of the condition. For example, subcategories under 410 designate the location of the infarction:
410.0 - of the anterolateral wall
410.1 - of other anterior wall
410.2 - of inferolateral wall
410.3 - of inferoposterior wall
410.4 - of other inferior wall
410.5 - of other lateral wall
410.6 - True posterior wall infarction
410.7 - Subendocardial infarction
410.8 - of other specified sites
410.9 - Unspecified site
Subclassifications are fifth-digit codes that add even more information and specificity. For 410, the fifth digit is 0, an unspecified episode of care, 1, the initial episode of care, and 2, a subsequent episode of care. The term episode of care is related to documented duration of treatment, not locations of treatment, explains Sue Prophet, RRA, CCS, director of classification and coding for the American Health Information Management Association in Chicago.
Not all codes have fourth or fifth digits, But if there is one available, you should use it, she says.
Fifth Digits a Must for MIs
0 -- episode of care unspecified. This ones easy because youll rarely use it. Although the fifth digit of 0 is designed for instances when the medical record documentation doesnt have enough information to determine the episode of care, you should ask the physician to get the necessary information, Prophet says. By properly specifying the episode of care, you will significantly reduce denials for your MI claims.
By finding out how long ago the patient was diagnosed with an MI, you can then classify the episode more specifically with one of the following fifth digits:
1 -- initial episode of care. Use 1 for the first episode of a newly diagnosed MI. This designation is used throughout the entire eight-week [...]
