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Home Health & Hospice Week

Diagnosis Coding:

CMN DOESN'T NEED TO JUSTIFY DIAGNOSIS CODE, CMS SAYS

Published on Tue May 13, 2003

You may still be in the dark as to which ICD-9 code to put on a claim in cases where Medicare now requires a four- or five-digit code. But at least you won't find yourself dinged for clashing with the codes on your certificates of medical necessity.

It doesn't matter if the diagnosis code on your claims matches the one on your physician order or CMN, as long as you can back it up, the Centers for Medicare & Medicaid Services says in April 18 program memorandum B-03-028. Evidence in the patient's medical record should support the use of that code, and the diagnosis code should support coverage for the item you're supplying.

You also don't need to obtain a new CMN for an existing patient if the CMN doesn't contain the most specific ICD-9 code, CMS confirms. Obviously if the patient's condition or order changes, then you'll need to obtain a new CMN in any case.

"CMS understands that physicians may not always provide suppliers of DMEPOS with the most specific diagnosis code, and may provide only a narrative description," the agency admits. If the physician leaves you without a clue, there are a few places you can hunt down the correct code, the agency adds, including:

  • coding books and resources,
  • contact with docs or other professionals,
  • documentation contained in the patient's medical record, or
  • verbal comments from the patient's physician or other clinician.

    Each line on your claims must have a valid diagnosis code. If not, electronic claims will bounce back to the supplier through front-end edits, whether they're assigned or unassigned. "These claims do not get in the front door," CMS insists.

    Also, you should make sure the ICD-9 codes you submit are actually valid and not defunct or fictional. Claims with invalid codes will slingshot back to you at top speed, unless the durable medical equipment regional carriers already are developing unassigned claims with invalid diagnosis codes prior to denial.

    Paper claims also require a valid ICD-9 code if the local medical review policy requires one.

    The Health Insurance Portability and Accountability Act requires a complete diagnosis code on each claim, unless it's a so-called "taxi claim" with no diagnosis. Essentially, CMS explains, a three-digit ICD-9 isn't acceptable if there's a four-digit code that provides more detail. And a four-digit code isn't acceptable if a five-digit code would provide more nuances as well.

     

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