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Gastroenterology Coding Alert

ICD-9 Coding:

It's as Easy as 3,4,5

Published on Wed Jul 07, 2004

Carry diagnosis codes out to the most specific digit possible

When a patient comes in for treatment of diabetes -- even non-complicated diabetes without insulin dependence -- coders must make sure they report a five-digit ICD-9 code. On the other hand, coders should report only a four-digit code for a benign neoplasm of the digestive system.

No doubt about it, diagnosis coding can definitely get confusing. And with the Centers for Medicare and Medicaid Services (CMS) demanding immediate implementation of its new ICD-9 codes from now on, it's plain to see that diagnosis coding isn't getting any easier.

Note: For more information on the latest ICD-9 code additions and the new rules for reporting them, see "Learn New Codes This Summer to Prevent Autumn Fall" in the June 2004 issue of Gastroenterology Coding Alert.

Get Those Digits

The first step to becoming a skilled diagnosis coder is remembering to carry ICD-9 codes to the appropriate digit, says Margaret Lamb, RHIT, CPC, coder at Great Falls Clinic in Great Falls, Mont.

Read on for expert tips on third-, fourth-, and fifth-digit ICD-9 coding, and get the most out of your diagnosis coding.

Non-Complicated Diabetes Requires 5 Digits

Example: The gastroenterologist treats a patient with diabetes. She is having no complications and does not require insulin. If you reported 250 (Diabetes mellitus), the diagnosis code will be rejected, Lamb says.

Why? "You need five digits to reflect complications and insulin dependence, or lack thereof. The code for non-insulin-dependent diabetes without complications would be 250.00 (Diabetes mellitus without mention of complication; type II)," Lamb says.

To double-check her ICD-9 coding, Lamb asks two questions:

1. Do I have a complete code?
2. Do I have the most specific complete code?

How will I know? You can check that you have the most complete and specific code when looking up the code in the ICD-9 book.

Look to the left of the ICD-9 code for non-complicated diabetes, and you'll see a red box with a check mark and "5th" printed in it. This box indicates that a complete ICD-9 code for this diagnosis must be five digits.

"Report the ICD-9 code that provides the highest degree of accuracy and completeness. That 'highest degree'refers to assigning the most precise ICD-9 code that most fully explains the [physician's] narrative description of the symptom or diagnosis," says JoAnn Baker, CCS, CPC-H, CPC, CHCC, an education specialist in East Orange, N.J.

'Complete'Not Always 5 Digits

Warning: Don't assume that you need a fifth digit on every ICD-9 code; some diagnoses require fewer than five numbers.

Example: The gastroenterologist removes a polyp from a 45-year-old patient's duodenum using hot biopsy forceps. You should:

  • report 43250 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) for the polyp removal.
  • include the appropriate ICD-9 code for the procedure. There are several acceptable codes for a polyp in the duodenum that justify an EGD with polyp removal, including 211.2 (Benign neoplasm of duodenum, jejunum and ileum).

    Don't forget: No codes will be accepted unless they are complete. Procedures in which a fourth or fifth digit was possible and a three-digit ICD-9 code was used are being rejected, Baker warns.

    In the above example, if you had linked 211 (Benign neoplasm of other parts of digestive system) to 43250, your claim would have been rejected because you didn't code to the highest degree of specificity. If you look to the left of 211 in your ICD-9 book, you'll see that 211 has a red box next to it with a check mark and "4th"; this means that a fourth digit is possible (and necessary) when using 211.

    How Can I Stay Sharp?

    Being a good ICD-9 coder is an ongoing challenge. An ICD-9 coder needs to "be knowledgeable in anatomy, disease process, surgical procedures, and keep updated on new technology," Baker says.

    If you are a good ICD-9 coder, you are also a great asset to your practice, since accurate ICD-9 coding is more important than ever before. Experts say that insurance carriers are getting more stringent (and savvy) in the diagnosis coding department and will reject claims for "lack of medical necessity" more often than in the past.

    Also, CMS has cracked down on nonspecific coding and eliminated the 90-day grace period designed for getting used to new ICD-9 codes.

    Note: For more information on the elimination of the grace period, see "Learn New Codes This Summer to Prevent Autumn Fall" in the June 2004 issue of Gastroen-terology Coding Alert.

    Curious about secondary ICD-9 codes, E codes, or V codes? Read about them in part II of our diagnosis coding special, coming next month in Gastroenterology Coding Alert.

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