EM Coding Alert

When in doubt, go back to your provider for details.

At some point, a superbill will cross your desk with no diagnosis code or diagnosis notes listed. When your provider forgets to add a diagnosis, that doesn’t mean you can’t bill the encounter. All you need to do is review the documentation to determine the appropriate diagnosis code you should assign to the claim.

Sticking to the following expert tips can help you successfully find the best ICD-9 codes for your physician’s claims — without too much headache on your part.

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

Suppose your provider hands you a superbill with the procedures circled and the diagnoses 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 Chandra L. Hines, practice supervisor of Wake Specialty Physicians in Raleigh, NC. In addition, the physician should be signing off on the diagnoses and the charges as part of your internal policy.

“I have permission to look at the report and put the diagnosis on the encounter form,” says Christy Shanley, CPC, CUC, billing manager for the University of California, Irvine. “If dictation is not available, then I go with form in hand back to the physician, or directly to the chart/or EMR (depending on site of service).”

Some practices choose to review the documentation and compare it against any diagnoses recorded on the superbill. This ensures that the documentation matches the code selection every time.

“Our procedure is to have physician to add the diagnosis to encounter form and make sure it is in chart,” Hines says. “The physician has to sign each encounter form. I do believe a certified coder could pull the proper diagnosis but the physician should sign off and agrees. I imagine we may be old school, but physician is responsible in the end so we should work together to make sure he dots the i’s and crosses the t’s.”

When in Doubt, Confirm With the Physician

If you are new at coding diagnoses from the provider’s notes, you should double-check your code selections with the practitioners before submitting your claims.

Until a coder feels comfortable with the ICD-9 books and the codes used most often in their office, it’s a good idea to run the choices by a clinician. You never want to give a patient a disease or symptom they don’t have, or one more severe (or less) than what they actually have. This may also be beneficial to the physicians because if you often select unspecified codes, the physicians may then strive to better document the patient’s condition into their notes to improve the coder’s ability to choose the correct diagnoses based on the physician’s documentation.

“I strongly agree,” Hines says. “Please don’t risk it. There is such a fine line to walk here. You may not do it on purpose, but putting the incorrect diagnosis on a claim can not only put your physician practice in jeopardy but you are also putting a diagnosis on the patient’s records that is so hard to take off.”

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 who needs to be scheduled for a cholecystectomy procedure. The form is missing diagnosis codes.

First step: You refer to the dictation, which reads: “The patient is a 43-year-old female being evaluated as a consultation at the request of Dr. Jones for abdominal and back pain. The pain started two weeks ago and has gotten worse.” The physician completes the remaining history, review of systems (ROS), past family and social history (PFSH), and physical examination.

Moving down through the chart note, you see that the patient brought with her the report and images from an ultrasound and abdominal CT. The radiology procedures came back normal.

Under a separate heading, the doctor has given his assessment and plan, which states: Probable cholecystitis and possible gall stones, Schedule cholecystectomy procedure and bile duct exploration.

Next step: If the diagnostic test was normal, but the referring physician records a suspected (a.k.a. probable, suspected, questionable, rule out, or working) diagnosis, you should not code the referring diagnosis. Instead, you should report the presenting signs and symptoms.

The ICD-9-CM guidelines warn, “The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for ordering the test.” For instance, suppose the physician’s notes indicated “suspected blockage of a bile duct by gallstones,” but the CT scan came out normal. Again, you would report the symptom (789.0x, Abdominal pain) rather than the suspected condition (i.e., 560.31, Gallstone ileus) as the reason for the test.