Medicare Compliance & Reimbursement

Urge your carrier to expand 1500 form to recognize multiple diagnoses.

Complex patients require more than a few diagnosis codes, and your carriers may finally be catching up.

What's new: The Centers for Medicare & Medicaid Services (CMS) recently issued a transmittal (CR5441) instructing carriers to consider all diagnosis codes on a claim, up to eight codes. The carriers have until July 1 to update the Medicare carrier standard system to meet this requirement.

This change will definitely help with conditions that require more than one code to report, such as diabetic complications, says Jan Rasmussen with Professional Coding Solutions in Eau Claire, WI. It also could help with preoperative V72.8x codes, where the medical necessity will come from the secondary codes, not the "V" code (see "Mistake: Listing Preop 'V' Codes As Primary Without Including Secondary Diagnosis" later in this issue).

If the carriers actually start considering multiple diagnoses for payment, then this will be a huge step forward, says Quinten Buechner with ProActive Consulting in Cumberland, WI.

For example: You may have a patient who's diabetic but also has high cholesterol and borderline high blood pressure. The patient might have a high-level evaluation & management visit because of the combination of all three of those problems, says Buechner.

The real problem: Will the carriers allow more than one digit in Box 24-E on the CMS-1500 form, which tells the carriers which diagnosis to assign to a particular procedure? Currently, you can list up to four diagnoses on the 1500 form, but some carriers will require you to put the number (from one to four) of the main diagnosis next to each procedure.

You should urge your carrier to allow you to list more than one digit in Box 24-E, Buechner says. For example, if the first, third and fourth diagnoses are relevant, you should be able to list "1, 3, 4" in the box. That would be a really helpful change, he says.

Otherwise, it doesn't matter how many diagnoses you can list, because all but one of them will be useful only for appeals, Buechner says. In an appeal, you can point to all eight of your diagnosis codes and say, "It's not my fault you can't figure out which ones really will apply, because you won't let me tell you which ones apply."

Accepting more than one digit in Box 24-E would also help the ongoing problem with screening colonoscopies that find a polyp, Buechner adds. You could list the screening "V" code first, but also add the polyp code and link to both in Box 24-E.