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Coding 101:

Think That Fifth Digit Doesn't Matter? Think Again

Published on Thu Aug 25, 2005 Print Friendly and PDF PDF

'Code jamming' could can your claims.

The next time the thought crosses your mind that the fifth digit probably doesn't matter, think about what it'd be like to lose your pinky finger. The fifth digit of an ICD-9 code is often as important to your claim as your fifth digit is to your hand.

Avoid this common shortcut: If you "code jam" -  fill in a 0 or 9, to get the fourth or fifth digit - you often will change the code's meaning.
 
Remember that the fourth and fifth digits represent further description of the root code, so by guessing the digit you risk misrepresenting the patient, warns consultant Christine Twombly with Reingruber & Co. in St. Petersburg, FL.

Accuracy Equals Money

Your goal is to paint as clear a picture as possible of the patient's condition(s) when choosing a code. For example, three-digit code 252 indicates a subsection "disorders of parathyroid gland." Four-digit code 252.0 further describes the disorder of the parathyroid gland as hyperparathyroidism. Taken a step further, 252.00 indicates hyperparathyroidism, unspecified, further describing the parathyroid gland disorder.

Thus, the five-digit code provides the most complete information about the patient's diagnosis, which is necessary in order to code to the highest level of specificity.

Not coding to the highest level of specificity possible almost guarantees claims denials. "ICD-9 coding allows for specificity and [information] falls through the cracks if not done correctly the first time," says Robyn Lee of Lee-Brooks Consulting in Chicago.

Shortcuts cost you: You actually lose time and money in the long run when you try to save time by using general codes, Lee points out.

Don't Make These Common Coding Mistakes

Payors most often reject or question claims for the following reasons: 

  • Unspecified codes (codes ending in .9);
     
  • Digits added inappropriately as space holders (adding one or two zeros to a three-or four-digit number to make it a five-digit code); and
     
  • Inappropriate primary diagnosis codes (e.g., reporting an acute fracture code when a V code represents the primary reason for home care).

    Communicate With Clinicians to Avoid Faulty Codes

    When clinicians document information correctly, you have a better chance of coding properly. Double-check with clinicians when in doubt about a patient's diagnosis, and let clinicians know exactly what kind of information you need to do your job correctly.
     
    And never code something without documentation to back it up - even if the proper diagnosis seems obvious to you.

    Warning: Improper coding can carry some serious repercussions for both the agency and the clinician, especially if the feds choose to interpret mistakes as intentional fraud, notes Quin Buechner, MS, CPC, with ProActive Consultants in Cumberland, WI.
     
    Among the possibilities are:  

  • lost reimbursement
     
  • fines
     
  • investigations
     
  • medical review and
     
  • loss of license.

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