Medicare Compliance & Reimbursement

Choosing the right CPT procedure code is the first step to ensure your physicians get paid for the work they do, but if you fail to attach the correct diagnosis code, you may be in jeopardy of receiving denials.

Follow these expert recommendations to ensure you're properly coding patients' signs, symptoms and diagnoses.

Correct coding requires that you code as specifically as possible. That means your physician should assign the most precise ICD-9 code to a service. You cannot justify a service with a four-digit diagnosis code when carriers or ICD-9 requires a more specific five-digit code to describe the patient's condition.

"Using the fourth or fifth digit when it is required--or just when you do have that information--is an important concept to follow," says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, FL. Make sure you review the entire record when determining the specific reasons for the encounter and the conditions the physician treated, she says.

Pitfall: Don't assume what isn't in the medical record.

Example: If you are coding for deep vein thrombosis (DVT), you cannot simply report 453.4 because four digits alone don't make for a complete diagnosis. Instead, you must specify a fifth digit of 0 (for DVT of unspecified vessels of lower extremity), 1 (for DVT of proximal lower extremity) or 2 (for DVT of distal lower extremity).

Tip: If the medical record does not allow you to code to the required level of specificity, check with the reporting physician for guidance.

When your physician provides a confirmed diagnosis, you should always code that diagnosis instead of the presenting signs and symptoms. If the physician cannot document a definitive diagnosis, however, report the patient's signs and symptoms to support medical necessity for services the physician provides.

Avoid "rule outs": ICD-9 coding guidelines state that you should not report "rule-out" diagnoses in the outpatient setting. You'll avoid labeling the patient with an unconfirmed diagnosis, and by coding the presenting signs and symptoms, your surgeon will still get paid for his services, even if he cannot establish a definitive diagnosis.

"Look to see if the physician has given the patient a definitive diagnosis," says Denae M. Merrill, CPC, coder for Covenant MSO in Saginaw, MI. " 'Rule out,' 'suspected,' 'probable' or 'questionable' are not codable. If there is no definitive diagnosis given, look for any signs or symptoms that the patient has been having."