Boost Practice Revenue with Comprehensive ICD-9 Coding
Published on Thu Oct 01, 1998
Sometimes diagnosis codes seem to get short shrift. Pediatricians, like most physicians, think that its the procedure codes that determine the reimbursement. For the most part, that is true. But, theres an uncomfortable trend taking root among insurance carriers, particularly managed care payers. Its called paying based on the diagnoses, instead of performed procedures. If the procedures of level of E/M code dont match the diagnosis code, in the payers opinion, then the claim is often downcoded or even denied.
To combat this, pediatric coders must ensure that they are listing the most specific ICD9 codes for the visit, and that they list all of the diagnosis codes that the visit covers.
Optimizing Office-Visit Coding
For example, you may find that a 99213 (level 3 office visit) with a diagnosis code for otitis media (385.82) is downcoded to a 99212 by the insurance company, says Donelle Holle, RN, reimbursement specialist for the University of Michigan Health System, Department of Pediatrics, in Ann Arbor. The child may have a raging fever, and the pediatrician may have had to do a CBC and a throat culture, says Holle. Whats the reason for a throat culture if the only diagnosis is otitis? To insurance carriers, there is no reason. So, you have to put down the diagnosis code for a fever as well. And its not only for testseven if the pediatrician sees that the ear is red and bulging, the doctor isnt going to stop there. The child must be examined. If the only diagnosis is otitis, you may find you are not getting adequately reimbursed, says Holle.
The answer is to use more than one diagnosis code. You can use up to four diagnoses per problem, emphasizes Holle. Pediatricians need to give the most information possible, because some companies are paying based on diagnosis codes. So, in the case of the otitis, you need to indicate what the child is presenting with. Here are two possibilities: 780.6 (fever) and 780.7 (malaise). Pediatricians often wont put the fever down, because they know its otitis, says Holle. But, we need to get everything on that claim.
Use 780 to 799.9
The codes for fever and malaise come from a section in ICD-9-CM that every pediatrician needs to look at, says Holle. This is the section on Symptoms, Signs and Ill-Defined Conditions and runs from 780 to 799.9. This section is essential for those situations in which you dont want to give a diagnosis youre unsure of, but you do want to be as specific as possiblea necessity under managed care.
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