Oncology & Hematology Coding Alert

If you continually make the same mistakes with oncology-related ICD-9 codes, you could attract audits from Medicare and private carriers. To avoid trouble down the road, you must learn and follow the correct procedures for submitting diagnosis codes. Coding experts offer these six tips for improving your signs and symptoms coding:
  
1. Know carriers' ICD-9 guidelines. You must know federal, state and private-payer diagnosis reporting requirements, says Pat Sevast, consultant with American Express Tax and Business services in Timonium, Md. If you demonstrate to payers that you followed their requirements, you can defend yourself when they look askance at your decisions. Obtain written rule documentation to safeguard your decisions.
 
For instance, you should be aware that beginning Oct. 1, all paper and electronic claims that you submit to Medicare carriers must contain a valid diagnosis code, except for claims submitted by ambulance suppliers, according to a June 6 CMS program memorandum (PM) B-03-045.  
 
The PM states, "Carriers must return as unprocessable paper and electronic claims that do not contain a valid diagnosis code ..." CMS also forbids carriers from "placing invalid or valid" diagnosis codes on claims for practices. (To read the PM, go to the CMS Web site www.cms.gov/manuals/pm_trans/B03045.pdf.)
 
Furthermore, you should submit ICD-9 codes that provide the highest degree of accuracy and completeness. This means that your oncologist should assign the most precise ICD-9 code to a service. You cannot justify a service with a three-digit diagnosis code when carriers require a more specific four-digit code to describe the patient's condition. For example, your oncologist lists 141 (Malignant neoplasm of tongue) instead of 141.0 (Base of tongue) or 141.1 (Dorsal surface of tongue). In this case, your Medicare carrier would deny your claim.
 
You should know your local medical review policies (LMRP) to ensure that you don't submit an unacceptable diagnosis code that will not prove medical necessity for services. Insurers cover some services based on the presence of certain diagnoses that identify medically necessary reasons for providing the service. If you don't supply these covered diagnoses, your carrier will deny your claim as not medically necessary.
 
For example, let's say Wisconsin Physician Service (WPS) Insurance Corporation serves as your Medicare carrier. Your oncologist performs a breast biopsy (19100*, Biopsy of breast; percutaneous, needle core, not using imaging guidance [separate procedure]) and lists diagnosis code 611.72 (Lump or mass in breast), which the insurer has approved as an acceptable code. So, more than likely, WPS will reimburse your practice for the service.
 
But if you attempted to justify 19100 with 174.x (Malignant neoplasm of female breast), which WPS doesn't regard as medically necessary for biopsy, the insurer would deny your claim.
 
You can obtain information about coverage and medical necessity through your LMRP at the CMS site http://www.cms.hhs.gov/mcd. Also, remember that carriers don't attach a policy to every service, but when they do, you want to be familiar with the requirements.
 
2. Always base coding on medical record documentation. You should be fanatical about reviewing documentation to ensure that records support the diagnosis codes you're reporting, Sevast says. But only oncologists should select diagnosis codes for claims unless you are a certified professional coder (CPC) and your physician has given you the responsibility to abstract the records.
 
3. Run system reports to discover claims with invalid codes. Make sure you keep up with the latest ICD-9 changes, says Catherine Brink, CMM, CPC, president of Health Care Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J. CMS and other carriers will reject your claims if you have not implemented the coding changes.
 
For example, as of Oct. 1, CMS will delete V04.8 (Need for prophylactic vaccination and inoculation against certain viral disease; influenza) and replace it with V04.81 (Need for prophylactic vaccination and inoculation, influenza), V04.82 (... respiratory synctial virus [RSV]) and V04.89 (... other viral diseases). Medicare, however, provides you with a deadline of Jan. 1, 2004, to stop using V04.8. If you submit any V04.8 claims after Jan. 1 instead of V04.8x, you'll face denials from Medicare for omitting the fifth digit.
 
You might need to report an inoculation code, for instance, if your oncologist were treating an elderly patient for advanced breast cancer (174.x), and the patient runs a risk for developed influenza (487.x), which threatens her life given her multiple medical problems. Your physician administers a flu shot, which you would report as G0008 (Administration of influenza virus vaccine) for Medicare patients, or 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; one vaccine [single or combination vaccine/toxoid]) and +90472 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) for most private insurers. You would list the diagnosis for vaccination as V04.81.
 
You cannot alter existing ICD-9 coding or documentation to match coding updates, Brink says.
 
4. Avoid defaulting to the "unspecified" code. When your oncologist provides you with a code that requires a fourth or fifth digit, don't default to an unspecified code. For example, your physician reports a patient's condition as 155 (Malignant neoplasm of liver and intrahepatic bile ducts), and you assign the digit that represents "unspecified" - which may not justify medical necessity in payers' eyes. Suppose you use 155.2 (... liver, not specified as primary or secondary) and do not seek out the most appropriate, specific condition, which could be either 155.0 (... liver, primary) or 155.1 (... intrahepatic bile ducts). In this case, your carrier could deny your claim because the code lacks specificity.
 
5. Don't code on assumption. If you see that your oncologist performs a specific treatment on a patient or prescribes certain medication, you may be tempted to assume that "a patient with that medication must have this diagnosis," Sevast says. Then when you review your oncologist's diagnosis choices, you may want to substitute them for your own choices. For example, your physician treats a patient with colon cancer and reports the diagnosis as 153.9 (Colon, unspecified). But you worry that this diagnosis does not accurately reflect the patient's condition, so you report 153.0 (Hepatic flexure) instead.
 
Don't. Coders should base their decisions on existing documentation, Sevast says. Review the patient's symptoms and the possible code selection with your oncologist to appropriately describe the patient's true condition and to educate your physician on the choices the ICD-9 book offers.
 
Also, remember that you shouldn't base codes on assumptions even to rule out possible and suspected conditions in a situation when your oncologist has not definitively diagnosed the condition. For example, your physician notes that a patient has presented with fatigue (780.79), excessive bruising (923.0x), and enlarged lymph nodes (785.6). Based on this information, you assign the patient's condition as lymphoid leukemia (204.0x). When your oncologist performs additional tests, he or she diagnoses the patient with monocytic leukemia (206.0x).
 
If you assign a specific diagnosis based on assumption, it could potentially lead to diagnosing a patient with a condition he or she doesn't have, which may result in the loss of insurance coverage or an increase in premiums, coding experts say. 
 
6. Never alter documentation. Even if you think your oncologist made a mistake or if you have a question concerning the documentation, always consult with your physician before you change anything. Your oncologist's chart is a legal document. Thus, your physician assumes responsibility for amending his or her documentation. If the chart needs changes, your physician should make the appropriate adjustments and follow the current legal standards of medical practice, coding experts say.