Ophthalmology and Optometry Coding Alert

Add these tips to your ICD-9 toolbox.

You won't get paid for your ophthalmic surgeon's work if you only focus on what he did; you also need to focus on why he did it. Choosing the right ICD-9 code tells the "why" story -- and that's the basis for demonstrating medical necessity for the procedure.

Follow our experts' tips to make sure you pick the right ICD-9 code to reflect your surgeon's diagnosis documentation, and to make sure you get paid.

1. Get the Big Picture

The first building block of a well-designed diagnosis coding policy is to adhere to the ICD-9-CM Official Guidelines for Coding and Reporting, says Tricia A. Twombly, BSN, RN, HCS-D, CHCE, senior education consultant and director of coding with Foundation Management Services in Denton, Texas. Not staying up to date with these standard rules can lead to trouble.

The official guidelines are updated each year and usually are available shortly after the annual ICD-9 code changes are made public. You can access the current guidelines at www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf.

Use outpatient rules: Note that the rules for outpatient diagnosis coding apply for physician services whether your surgeon performs a procedure in an inpatient or outpatient setting.

Coder tip: Read the official guidelines that apply to your specialty periodically as a refresher. "If we only read them when the codes change once a year, it is difficult to absorb and retain that information for an entire year," says Lisa S. Martin, CPC, CIMC, CPC-I, chargemaster specialist for OSF Healthcare System in Peoria, Ill.

Keep current: Whether the official guidelines or the ICD-9 codes themselves, you should use only the most current version when selecting a diagnosis code. "Regardless of the resource, the most important factor is that it is up to date," Martin says. Using an invalid code will always trigger a denial.

2. Begin in the Index; Proceed to the Tabular List

The first general coding guidance you'll find in the ICD-9 official guidelines is to always use both the alphabetic index (Volume 2) and the tabular list (Volume 1). Relying on just one section "leads to errors in code assignments and less specificity in code selection," according to the guidelines.

Start with index: You should always begin your code search by first consulting the alphabetic index, which is arranged by condition.

When you have narrowed your search using the index, cross-reference the codes using the tabular listings, and read the precise definition of your tentative code selection. The tabular listing typically provides additional information such as other common terms that report to the same code, or terms that are excluded from the code.

If you code directly from the alphabetic index, you'll miss valuable information that will help you pinpoint the exact code you need. That's why you should always read the notes in the ICD-9 manual that apply to the code you're considering, says Denae M. Merrill, CPC, HCC coding specialist in Holland, Mich.

Example: "Visual disturbance" is listed as ICD-9 code 368.9 in the alphabetic listing. When cross-referenced to the tabular index, the visual disturbance code is listed as "unspecified." However, more specific information is listed prior to the unspecified listing to accurately code a claim as to the type of visual disturbance the patient is experiencing and can be found in the family of 368.XX codes. "These codes should be reviewed to determine the most specific diagnosis code assignment," cautions Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Ambulatory Hospital and Network Oversight at the Mount Sinai Medical Center Compliance Department in New York City.

Coder tip: Don't be afraid to write a lot of your own notes in the margins and make good use of your highlighters, says Martin. "I even make notes in the index because where you initially expect to find something is where you will search again in the future."

Alert: Your surgical practice might have a "cheat sheet" that lists common conditions that your surgeon treats and the associated ICD-9 codes. Take care when using cheat sheets, Merrill cautions. They can be helpful as long as you don't rely on them too heavily. And you absolutely must be sure you update them regularly.

3. Be Specific

You must always report the most specific ICD-9 code you can, based on the surgeon's documentation. That means reporting codes "at their highest number of digits available," according to the official guidelines.

In other words, you must use four- or five-digit codes when they're available. You should never report a category (three-digit) or subcategory (four-digit) code when ICD-9 lists more specific codes under those headings -- your claim will reject if you do.

Coder tip: Although there's no standard format for ICD-9 books, many editions have an indicator that a code requires additional digits. Use these reminders if they're available to you.

Don't be too specific: Reporting to the highest degree of specificity doesn't mean guessing at information not in the medical record or coding preliminary diagnoses as final. If you don't have specific information, you'll need to use a "not otherwise specified" (NOS) or "unspecified" code using the proper number of digits.

"Every attempt should be made to speak with the provider to obtain more specific information when necessary," Mac advises. "This should also be a prelude to helping the physician document the patient diagnosis more specifically, especially with the coming of ICD-10 and need for better documentation."

Regarding preliminary diagnoses, you shouldn't code "rule out," "suspected," "probable" or "questionable" statements in the medical record. If you don't have a definitive diagnosis, "look for any signs or symptoms that the patient has been having," Merrill says.

Caution: Don't use unspecified codes for a condition that's specified in the medical record, but doesn't have a specific ICD-9 code. Instead, you should select a code that uses the terminology "other," "other specified," or "not elsewhere classifiable (NEC)." In other words, the lack of specificity lies in ICD-9, not in the documentation.

Coder tip: Often, but not always, NEC codes end with a final digit of "8," while NOS codes end with a final digit of "9."