Pathology/Lab Coding Alert

The new ICD9 Codes that will go into effect Oct. 1, 2000, include the expansion of several codes to require an additional digit. That should serve as a reminder to coders that officials from the Health Care Financing Administration (HCFA) and many third-party payers expect specific diagnosis coding. Ignoring those expectations may lead to claims denials and audits.

Coders can make the error of non-specific diagnosis coding in two ways. One is the assignment of a truncated code, which means reporting fourth and fifth digit codes only to the third or fourth digit, respectively. As the Official ICD-9-CM Guidelines for Coding and Reporting explains, A code is invalid if it has not been coded to the full number of digits required for that code.

The second way coders err is in the overuse of unspecified (NOS) codes. The guidelineswhich are approved by HCFA, the American Hospital Association, the American Health Information Management Association, and the National Center for Health Statisticsalso warn against this, stating codes labeled unspecified are used only when neither the diagnostic statement nor a thorough review of the medical record provides adequate information to permit assignment of a more specific code.

Medicare and many third-party payers consider truncated coding invalid and question the overuse of unspecified codes. Clearly there are times when some of these codes must be used for lack of more definitive information, states Stacey Hall, RHIT, CPC, CCS-P, director of corporate coding for Medical Management Professionals Inc. in Chattanooga, Tenn., a national billing and management firm for hospital-based physician practices. But they should not be reported when a more specific diagnosis is evident from the medical record.

By observing a few simple guidelines, however, coders can ensure that they are meeting HCFA and other payers requirements to report diagnoses to the highest degree of specificity.

1. More digits equals more detail. ICD-9 contains codes with three, four or five digits. Most three-digit codes serve as headings for broad categories, which need to be further divided. Categories are subdivided by adding a decimal pointas well as a fourth and/or fifth digitafter the third digit. The fourth and fifth digits provide more detail about the nature of the disease or condition. Those codes with fourth digits are called subcategory codes, while those with fifth digits are sub-classifications. The rule is, if a fourth or fifth digit is available, you must use it.

For example, Coding for gallstones (574) requires a good understanding of these principles, says Hall. The
stones (calculus) can occur in the gallbladder or the bile duct, and they can [...]