General Surgery Coding Alert

If your diagnosis coding fails to support medical necessity for the services and procedures provided, carriers can deny claims outright or may require repayment (along with additional fines or even fraud investigations) at a later date. Even when a procedure or service is medically necessary and appropriate, faulty ICD-9 coding can derail the claim. Here are three tips to help you ace your diagnosis coding.

In all cases, you should strive first and foremost to report ICD-9 codes that accurately and completely describe the patient's condition as supported by physician documentation. Never assume that a diagnosis applies. Be sure that there is sufficient information in the encounter or operative note to support any ICD-9 codes you assign. If documentation is unclear, ask the reporting physician for guidance.

In the same vein, always be sure that you report a diagnosis to the highest available and supportable specificity level. Including fourth and fifth digits, when available, to any ICD-9 codes you report is incredibly important for both proper coding and timely payment.

The second goal of successful diagnosis coding is to establish medical necessity for any services and procedures the patient receives. Medicare sets the standard for all payers by defining medical necessity as "those services or items reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member."

Medicare further qualifies "reasonable and necessary" to mean that a service or procedure is:

- Safe and effective;

- Not experimental or investigational; and

- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition, or to improve the function of a malformed body member;

- Furnished in a setting appropriate to the patient's medical needs and condition;

- Ordered and furnished by qualified personnel;

- One that meets, but does not exceed, the patient's medical need; and

- At lease as beneficial as an existing and available medically appropriate alternative.

Many payers will establish guidelines that state explicitly which diagnosis codes they will accept to establish medical necessity for a given CPT or HCPCS procedural code, and you can find these codes in the payers- local coverage determinations (LCDs) for various procedures.

You must always observe diagnosis coding's first rule: Only report a diagnosis supported by documentation. You should never assign an ICD-9 code merely for the purpose of achieving payment by falsely claiming medical necessity. This is fraudulent, which can result in serious financial and criminal consequences, and can harm patient outcomes.

With the physician's documentation as your guide, you should bill as many diagnosis codes as you need to establish medical necessity for the services you-re billing. Medicare guidelines now allow up to eight ICD-9 codes on a claim.

In addition, you should always report diagnoses to the highest available degree of specificity. Therefore, you must use four- or five-digit codes when they are available. You should never report a category (three-digit) or subcategory (four-digit) code when ICD-9 lists more specific codes under those headings.

The introduction to the ICD-9 manual provides a good summary of "10 Steps to Correct Coding," and you should follow these steps as a guide when selecting diagnosis codes.

The most important of these steps is to begin your code search by first consulting the alphabetic index, which is arranged by condition. When you have narrowed your search using the index, cross-reference the codes using the tabular (Volume 1) listings, and read the precise definition of your tentative code selection. Often, the tabular listing will provide additional information that will help you pinpoint the exact code(s) you need.

Example: You need to find a diagnosis for nonalcoholic cirrhosis of the liver. Check the ICD-9 index under "Cirrhosis," which contains the "general" code 571.5. By looking further, to the sub-entries, find the location (liver), which also points to 571.5.

Next, find 571.5 in the tabular listing. Under this code, ICD-9 confirms "Cirrhosis of liver without mention of alcohol" and provides a further definition, "Fibrosis and dysfunction of liver; not alcohol related." Now, you can select 571.5 with confidence.