Neurology & Pain Management Coding Alert

You know that your diagnosis coding needs to support medical necessity for the services and procedures provided. If it doesn-t, carriers can deny claims outright or may require payment -- along with additional fines or even fraud investigations -- at a later date. Faulty ICD-9 coding can derail claims even when a procedure or service is medically necessary and appropriate. Here are some ways to keep your diagnosis coding on-target.

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

The single most important step is to begin your code search by first consulting the alphabetic index, which is arranged by condition. Narrow your search using the index. You should cross-reference the codes using the tabular (Volume 1) listings and read the precise definition of your tentative code selection. The tabular listing provides additional information that will help you pinpoint the exact codes you need.

For example: If you need to find a diagnosis for epilepsy related to the abdomen without loss of consciousness, check the ICD-9 index under "Epilepsy." This contains the "general" code 345.x. Looking in the sub-entries, you-ll find the location (abdomen), which also points to 345.5x.

Now find 345.5x in the tabular listing. Under this code, ICD-9 confirms "Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures" and provides a further definition, "partial NOS: without impairment of consciousness." You can select 345.5x with confidence now.

Play it safe: Never choose a code without referring to the ICD-9 index (Vol. 2) first, then to the tabular section (Vol. 1) for confirmation and specificity. Be sure to read any coding notes to assist in accurate assignment.

Always be sure that you report a diagnosis to the highest available and supportable specificity level. You need to use four- or five-digit codes when they are available. Never report a category (three-digit) or subcategory (four-digit) code when ICD-9 lists more specific codes under those headings. Thorough reporting ensures proper coding and timely payment.

You should strive to report ICD-9 codes that accurately and completely describe the patient's condition as supported by physician documentation. Using 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.

Tip: "See if the physician has given the patient a definitive diagnosis," says Denae M. Merrill, CPC, coder for Covenant MSO in Saginaw, Mich. " -Rule out,- -suspected,- -probable- or -questionable- are not codeable. If there is no definitive diagnosis given, look for any signs or symptoms that the patient has been having."

Problem spot: "Generally speaking, the ICD-9-CM nomenclature does not serve the neurology specialty well for certain conditions," says Marianne Wink-Sturgeon, RHIT, CPC, ACS-EM, at University of Rochester Medical Center, New York.

She points out that general symptom codes for numbness, 782.0 (Disturbance of skin sensation) and 780.99 (Other general symptoms), may cause rejections. Upon study, Wink-Sturgeon says, these conditions can actually turn out be serious and can require time and diagnostics to confirm a more specific diagnosis.

Wink-Sturgeon says that documentation should always describe patient symptoms as specifically as possible for coding specificity, while noting hopefully that ICD-10 may provide better coding options in the future.

Important: Never assume that a diagnosis applies. Make sure that there is sufficient information in the encounter or operative note to support any ICD-9 codes you assign. If the documentation is unclear, always ask the reporting physician for guidance.

One major goal of successful diagnosis coding is to establish medical necessity for any services and procedures the patient receives.

"If a diagnosis is not in the National Coverage Policy, then the necessity of the rendered service for the problem could warrant a clinical review and supporting documentation from the physician to justify the procedure," Wink-Sturgeon says.

Tip: 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.

Wink-Sturgeon says to consider further conditions for reimbursement for a procedure. If that does not turn out to be the case and the service is not covered, you should notify the patient that she may be responsible for payment. Complete an Advance Beneficiary Notice prior to performing the procedure.

Always observe the first rule of diagnosis coding: 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.