Oncology & Hematology Coding Alert

Watch out: 1 common coding tool could be costing you time and money

 Finding the right diagnosis code for your Hodgkin's patient can require some real sleuthing skills. Good news: The clues you need for success are right in your ICD-9 manual. See what the experts suggest when hunting down the most specific code.

Why it matters: Payers look at the ICD-9 code to determine whether the diagnosis supports medical necessity for the treatment plan and any ancillary services, such as radiology or 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 teleconference, -Accurate Neoplasm Coding Step-by-Step.-

Sample diagnosis: Suppose your documentation says your patient has Hodgkin's disease, nodular sclerosis, intrapelvic lymph nodes. Here's how to determine the appropriate diagnosis codes.

1. Begin Your Search in the Alphabetic Index

 Your first instinct when coding cancer may be to head to the neoplasm table, but when you have the name of a specific condition, you should look up the term in the alphabetic index instead.
 
Example: To find the appropriate code for our sample diagnosis, you should look up -Hodgkin-s- in the alphabetic index. The listings for Hodgkin's disease include an entry for nodular sclerosis -- 201.5.

2. Let Symbols Guide You to Greatest Specificity

 Many ICD-9 manuals include symbols to alert you when a code requires an additional digit.
 
Example: The alphabetic index entry for -Hodgkin's disease, nodular sclerosis- in the AMA's Physician ICD9-CM 2007, Volumes 1 and 2, has a checkmark next to the entry, meaning -additional digit required -- refer to the tabular list for digit selection.-
 
Tip: Learn the symbols your ICD-9 resource uses so you won't miss any clues regarding whether you need a more specific code.

3. Verify Your Choice in the Tabular List

 You should always look in the tabular list to read the code descriptor and ensure that you-re reporting the most accurate code, regardless of whether the alphabetic index listing directs you to the tabular list.
 
Example: You turn to 201.5 and see the descriptor Hodgkin's disease; nodular sclerosis.
 
In many manuals, this entry offers another reminder that you need to look for an additional digit with a symbol such as --5th- or -+.- Note: If you instead turned first to 201 (Hodgkin's disease) you might see a symbol, such as --4th,- reminding you that the three-digit code 201 is incomplete. When you narrow in on four-digit code 201.5, you-ll see the symbol directing you to add another digit.
 
Key idea: If the ICD-9 code you submit is not as specific as carrier rules require, the carrier may reject the claim for lack of medical necessity or simply because you reported a truncated code, says Margaret Lamb, RHIT, CPC, coding expert in Great Falls, Mont.
 
Bonus: The tabular list has -includes- and -excludes- notes, which help you identify whether you have the correct code. Often when there is a more specific code, the instructions will provide a cross-reference to the appropriate code or category.

4. Search Out Fifth-Digit Options

 Don't give up if you can't locate five-digit codes right away. Depending on your manual's layout, you may find that it lists some fifth-digit options directly under the four-digit codes, while others gather fifth-digit options and list them before the categories that they apply to.
 
Example: To locate the appropriate fifth digit for 201.5, you turn to the box listing fifth-digit subclassifications for categories 200-202 located at the beginning of the 200 range, below the heading -Malignant Neoplasm of Lymphatic and Hematopoietic Tissue (200-208)-:

0 -- unspecified site, extranodal and solid organ sites
1 -- lymph nodes of head, face, and neck
2 -- intrathoracic lymph nodes
3 -- intra-abdominal lymph nodes
4 -- lymph nodes of axilla and upper limb
5 -- lymph nodes of inguinal region and lower limb
6 -- intrapelvic lymph nodes
7 -- spleen
8 -- lymph nodes of multiple sites. 

 Your documentation says your patient has Hodgkin's disease, nodular sclerosis, intrapelvic lymph nodes. The fifth-digit subclassification that best describes this diagnosis is 6 (intrapelvic lymph nodes).
 
Result: Your final ICD-9 choice is 201.56 (Hodgkin's disease; nodular sclerosis; intrapelvic lymph nodes).

5. Challenge Your Choice With 2 Questions

Ensure you use the most accurate ICD-9 code every time by asking two questions before sending out a claim,  Lamb says:
  
1. Do I have a complete code?
2. Do I have the most specific complete code?

 For our sample diagnosis, you-ve selected the five-digit code that most accurately describes the patient's diagnosis, so you can feel confident sending in your claim.
 
Common culprit: Coding -cheat sheets- often don't list fifth digits, so if you only use a cheat sheet to code, you could be setting yourself up for denials due to incomplete codes.