Ob-Gyn Coding Alert

A common problem in ob/gyn diagnosis coding is the failure to reach the highest possible level of specificity. What I see too often is physicians writing down a general diagnosis, such as abdominal pain or hypertension, and the coder then using the unspecified code, says Deb Lief, CPC, president of the North Texas Chapter of the AAPC and manager of coding compliance for ProMedCo, a practice management firm in Fort Worth, TX. The result is that the practice experiences claim denials, loses money and may be putting itself in jeopardy of losing more money in the future, she says. The solution is in assuring that diagnosis coding is as specific as possible. This is accomplished by understanding the relationship between specificity and reimbursement, always practicing thorough coding processes and creating a complementary partnership between the coder and physician.

How Specificity Affects Reimbursement

Currently, reimbursement is based on CPT procedures and services, not on the diagnosis codes. But the reimbursement for services and procedures depends upon whether credible medical necessity has been established by applying the correct diagnosis codes. Those codes reflect to the payer why the services or procedures were performed. According to Lief, payers are giving more attention than ever to the diagnosis codes. And increasingly, reimbursement is being denied if the ICD-9-CM codes are not specific enough. For example, if you code for a diagnostic laparoscopy (56300), the payer wants to make sure the procedure is justified and will be looking hard for diagnosis codes that do not prove medical necessity. Just coding abdominal pain 789.00 is not enough. You need to be precise about location (upper, lower, left, right quadrant) and list any other symptoms. If the coding is not carried to this level of specificity, payment may be denied or downcoded. This is especially important when trying to show medical necessity in the higher levels of E/M coding. When coding for such problems as PID, menstruation problems, hypertension and diabetes, code selection should reflect precisely everything that is known about the problem (i.e. the specifics of the inflammation for PID).

According to Lief, diagnosis codes are only going to become more important in the future. I see diagnosis-based reimbursement coming in a few years, she says, pointing out that Medicare, HCFA and many commercial carriers are already beginning to keep databases on each physicians code use. In the near future, this data could be used to guide payment, as capitated coverage spreads. If you are not coding to the highest level of specificity, payers will look at your data and may assume that you are not seeing the higher levels or more complicated patients, and will only pay for the level of patients your diagnosis coding reflects. Therefore, [...]