Oncology & Hematology Coding Alert

You need to pay special attention to this V code rule

You can cut out a good chunk of time-consuming appeals - and boost your accuracy rate - if you apply a few diagnosis coding fundamentals up-front.

Get started: Follow these expert recommendations to ensure you-re properly coding patients- signs, symptoms and diagnoses.

1. Block Denials Using All Possible Digits

Correct coding requires that you code as specifically as possible. That means you should assign the most precise ICD-9 code to a service.

How to do it: Use the fourth or fifth digit when ICD-9 requires it, says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, Fla. Make sure you review the entire record when determining the specific reasons for the encounter and the conditions the physician treated, she says.

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.

Example: If you are coding for cervical cancer, you cannot simply report 180 (Malignant neoplasm of cervix uteri) because three digits alone don't make a complete diagnosis. ICD-9 offers four-digit options, which you must use instead, such as 180.0 (- endocervix).

Pitfall: Don't assume what isn't in the medical record. If the medical record does not offer the information (such as anatomic region) that you need to choose the most specific code, check with the reporting physician for guidance. If the physician doesn't supply the information you need, choose an -unspecified- code, such as 180.9   (... cervix uteri, unspecified), rather than reporting 180 without a fourth digit or randomly choosing another fourth digit.

Watch out: Coding -cheat sheets- often don't list fifth digits, so you should always check your code choice in the ICD-9 manual. You also don't want to rely on unspecified codes too often. Payers believe that if a doctor treats a lesion with radiation or chemotherapy, he-d better know - and document - exactly where it is.

Bottom line: Payers are sure to reject claims that use truncated ICD-9 codes (shortened by dropping one or more digits after the decimal point). Nip denials in the bud by accurately reporting all possible digits.

2. Stop Skipping Over Signs and Symptoms

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

Key point: Payers use ICD-9 codes to determine whether medical necessity exists for the treatment plan and ancillary services, such as labs, says Carolyn M. Davis Hutt, CMA, CPC, CCP, CCS-P, CPHT, RMC, reimbursement coordinator with Oncology Hematology West in Omaha, Neb., in her Coding Institute audioconference, -Accurate Neoplasm Coding Step-by-Step.- (Learn more at www.audioeducator.com, where you can order CDs or transcripts of this presentation.)

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 when you code the presenting signs and symptoms, the payer should cover your oncologist's services, even if he cannot establish a definitive diagnosis.       

CMS outpatient service guidelines also explicitly state that practices should not use the condition being ruled out as the diagnoses. Instead, -code the condition(s) to the highest degree of certainty for that encounter/visit such as symptoms, signs, abnormal test results ...-   

You should not code diagnoses the doctor documents as -rule out,- -suspected,- -probable- or -questionable,- says Denae M. Merrill, CPC, coder for Covenant MSO in Saginaw, Mich.  If the doctor doesn't give a definitive diagnosis, -look for any signs or symptoms that the patient has been having,- she says.

Example: The oncologist sees a patient with a very high fever and suspects that she has sepsis.

Correct coding in this instance depends on available documentation. If the oncologist states that the diagnosis is sepsis, report the relevant documentation-supported code (for example, 995.92, Severe sepsis). If the physician stated that he was attempting to -rule out- sepsis, you should report the signs and symptoms (for example, 780.6, General symptoms; fever).

Pointer: Talk to your physicians about how important term accuracy is. Tell the physician that if he can come to a definite conclusion about the patient's diagnosis, he needs to state this in his dictation so you may choose the best code.

3. Use V Codes When Applicable

Coders often hesitate to report V codes, but sometimes they may be the most accurate descriptors of the reason for the patient's condition. Actually, you should use V codes to provide additional clinical information to an insurer, whether it's Medicare or a private carrier.

Most coders believe that V codes are appropriate only as secondary codes, but the reality is that you may - and on occasion should - report V codes as a primary diagnosis. This is especially important in oncology because ICD-9 guidelines instruct you to report chemotherapy and/or radiation encounter V codes as the primary diagnosis for patients who present primarily for these services.

Example: According to ICD-9 guidelines, you should use a V code, such as V58.11 (Encounter for anti-neoplastic chemotherapy), as the primary diagnosis code when the patient presents only for chemotherapy.

Tip: Many versions of the ICD-9 manual will indicate whether you can report a V code as a primary or secondary diagnosis using the indicators -PDx- (primary) and -SDx- (secondary) next to the code descriptor. If the code has neither a -PDx- nor an -SDx- designation, you may use that V code as either a primary or a secondary diagnosis, according to ICD-9 instructions.