Gastroenterology Coding Alert

Make sure the gastroenterologist approves the codes before filing

There's a right way and a wrong way to check ICD-9 codes before you send claims out the door. As a coder, you will usually be the last one to see a claim before it heads to the insurer.

That's a hefty responsibility, but not an impossible one to bear as long as there is open communication between coders, gastroenterologists and other office staff, says JoAnn Baker, CCS, CPC-H, CPC, CHCC, an education specialist in East Orange, N.J.

"In order to assign a diagnosis code, you have to make sure you can read the medical record, extract that info out of there, and attach a proper ICD-9 code," Baker says. If coders feel as if they're on their own when diagnosis coding, they may not be inclined to ask a nurse or physician when they have a question about a diagnosis.

"Communication is essential to achieve complete and accurate documentation, code assignment and reporting of diagnoses and procedures," Baker says.

Solution: Follow these expert instructions every time you file a claim to ensure accurate and complete ICD-9 coding.

The coder should first gather and check all relevant documentation for ICD-9 codes, since the gastroen-terologist may not always put the diagnosis code on the face sheet.

"Review any progress notes, operative reports, laboratory, radiology, nurse's notes, medication sheets and graphs, along with the discharge summary" in the search for diagnoses codes, Baker says.

"If there's any question as to what the diagnosis is, you should query the physician regarding the diagnosis or procedure method," Baker says.

When an ICD-9 code is unclear to Margaret Lamb, RHIT, CPC, coder at Great Falls Clinic in Great Falls, Mont., the gastroenterologist who performed the procedure is the first person she contacts.

Example: You are looking at a claim with a diagnosis code of 530.1 (Esophagitis) linked to an EGD with biopsy (43239, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple).

However, in the discharge summary, you see a note indicating that the patient also has some reflux with the esophagitis, which would make 530.11 (Reflux esophagitis) the proper diagnosis code. In this situation, the coder should immediately point this out to the doctor and ask him if that's what he meant to do.

Consequence: If you file the above claim with 530.1 as your diagnosis code, it may be denied due to lack of specificity -- illustrating why the coder should communicate with the doctor when checking ICD-9 claims, Lamb says.

In fact, Baker thinks that the gastroenterologist should always be the one putting the ICD-9 codes on claims, since he's the one who actually evaluates the patient.

"If unsure about any coding choice, I utilize the resources available to me: discussion groups, newsletters, other coders, etc.," Lamb says. "For ICD-9 coding, the American Hospital Association's [AHA's] Coding Clinic is the most respected and utilized resource."

If you've reviewed all the documentation and conferred with the doctor, and you're still stuck, contact the individual insurance carrier.

When you are filing with a private insurance company, call the representative and ask if your ICD-9 code will be accepted for the procedure. While you've got the representative on the phone, it wouldn't hurt to ask him what other ICD-9 codes are acceptable diagnoses for the procedure you are filing.

If you're dealing with a Medicare carrier, check your area's local medical review policies to see if the carrier covers your diagnosis code as medically necessary for the procedure.