Neurosurgery Coding Alert

If you don't know what differentiates an acute condition from a chronic one, or how many diagnosis codes you can report, you could find yourself assigning the wrong code.

Before jumping to conclusions, check out the following two frequently asked questions to get quick tips to help your ICD-9 coding.

Question 1: Our physician treated a patient with diabetes, but he was actually seeing the patient to treat a complication of the diabetes, diabetic neuropathy. During his evaluation, the physician also noted that the patient had joint inflammation. Should we report the neuropathy complication only, or several of the ICD-9 codes?

Answer 1: Normally, the primary diagnosis code that you list on your claim should represent the main reason for the encounter, or the condition with the highest risk of morbidity/mortality that the physician addresses during the visit. The situation changes, however, when you deal with a condition like diabetes.

According to Section 1.A.6 of the ICD-9-CM Official Guidelines for Coding and Reporting, "Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation."

The guidelines continue, explaining that you may report more than one code from category 250 to "fully describe the patient's complete diabetic condition" if the patient has "more than one manifestation of diabetes."-

Therefore, you should first report 250.6x (Diabetes with neurological manifestations) on the claim. Remember to add a fifth digit to reflect the type of diabetes the patient has.

Your secondary code should represent the specific neurological manifestation. In most cases, you will report 357.2 (Polyneuropathy in diabetes). Because the neurosurgeon documented that the patient also has joint inflammation, you should report the appropriate diagnosis code describing that condition (716.9x, Arthropathy, unspecified).

Although the insurer's computer will scan only the first, main diagnosis code that you list, you should include all of the codes that apply.

That way, if the payer challenges a claim, you can help your appeal by having already sent the insurer all the patient's applicable diagnoses on record.

Question 2: The 1997 audit guidelines state that I can reach an extended history by updating the status of at least three chronic or inactive conditions. Our physician likes to refer to this information in both the history of present illness (HPI) section of the note as well as the assessment section of the note. Is this a good idea?

Answer 2: Although some physicians reference the illnesses in the assessment section of the medical decision-making (MDM) section, some choose to also discuss the illnesses in the HPI notes. Many coding consultants, however, discourage physicians from documenting the illnesses in two separate sections unless you specifically address that issue during the visit.

"I would recommend not counting this twice (once in HPI and again in MDM)," says Bruce Rappoport, MD, CPC, a board-certified physician who works with doctors on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.

"If you use this as an element of HPI and it isn't being documented as part of the medical necessity, I would not count this additionally as part of the MDM," he says.

If the physician does address the chronic condition, the documentation should be distinct for HPI and MDM. Most likely, however, the physician is not focusing on or addressing these conditions during the visit.

Using the 1997 guidelines may help you report higher-level services for patients who have chronic conditions, such as diabetes and asthma. Unlike the 1995 version, the 1997 history elements don't require the four HPI elements for an extended level because you can use the status of three or more chronic conditions.

Therefore, the 1997 guidelines may allow you to report a higher-level E/M code for encounters that involve periodic prescription renewals without your neurosurgeon having to go into as much detail.

Don't Mix and Match 1995 and 1997 Guidelines

Be careful: You can only use the 1995 or 1997 guidelines individually, but you cannot pick and choose aspects from both sets of guidelines to achieve a higher E/M level. Select one set of guidelines (either 1995 or 1997), and stick with them.

Know your carriers: "Some payers have created audit tools that combine the guidelines in certain areas," says Suzan Hvizdash, CPC, CPC-EDS, CPC-EMS, a coding consultant and physician educator for the department of surgery at the University of Pittsburgh Medical Center. "You-ll want to check with your top payers to see what audit tools they use and make certain to stay current with them from time to time."

Remember: Medical necessity should ultimately drive the visit's history and examination.

"If the physician does not indicate the status of the patient's conditions, but only mentions that the patient has them, the examination aspect of the guidelines does not apply," Hvizdash says.