Pediatric Coding Alert

Improve reimbursement with these tips

Using the correct ICD9 Coding doesn't just ensure coding compliance - it increases the potential for higher reimbursement. The key to accurate diagnosis coding is specificity.
 
CPT codes explain to a payer what service a pediatrician/physician performed, but the ICD-9 codes explain why the physician performed the service. And if the diagnosis codes don't sufficiently explain the medical necessity for a procedure, appropriate reimbursement is less likely.
 
For example, don't link diagnosis code 382.9 (Unspecified otitis media) to cerumen removal (69210, Removal impacted cerumen [separate procedure], one or both ears). Cerumen removal is not necessary to diagnose the infection. Impacted cerumen has its own code, 380.4, which may be linked to 69210, but they are a separate diagnosis and procedure unrelated to otitis media.
 
The biggest mistakes coders make with diagnosis codes is not coding to the highest order of specificity and not accurately assigning fourth or fifth digits. According to Medicare, claims with truncated diagnosis codes will be denied.

Don't Consider 3-Digit Codes the Norm

ICD-9 contains codes with three, four and five digits. Most three-digit codes serve as headings for broad categories, which then need to be broken into more specific codes. The fourth and fifth digits, which follow a decimal point added to the core three-digit code, provide more detail about the nature of the disease or condition the pediatrician is treating.
 
Some diagnosis coding lingo: Codes with a fourth digit are called "subcategory" codes, and codes with a fifth digit are called "subclassifications."

 If you find yourself assigning 3-digit diagnosis codes frequently, take it as a warning sign. Use three-digit diagnosis codes only when a fourth or fifth digit is not available.
 
For example, according to ICD-9, the three-digit diagnosis code 009 describes "Ill-defined intestinal infections" and requires a fourth digit. Without more information, this diagnosis provides the payer with only a general idea as to what treatment options are appropriate, and therefore the payer will reject any claim with such a diagnosis. You should be more specific, which may be required to determine the necessary service, by using additional digits.
 
In the case of 009, a fourth and fifth digit can be used to specify the type and status of the infection; for example, code 009.0 indicates infectious colitis, enteritis, and gastroenteritis; and 009.2 is for infectious diarrhea.
 
On the other hand, if you have a legitimate reason to report a three-digit code, you should. For example, if the diagnosis code that the condition requires does not have fourth- and fifth-digit options, you should report the three-digit code. You won't always be able to report a fourth or fifth digit - the key is to do so whenever it's possible.
 
"Some payers use ICD-9 codes to measure outcomes for physicians," says Barbara Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a billing company in Lakewood, N.J. "Outcomes affect reimbursement, fee schedule negotiations, and the future of contract renewal with a payer."
 
If a pediatric practice continues to report unspecified diagnoses, the practice's data will be incomplete and the outcomes information will be skewed, which can hinder the pediatrician's ability to negotiate future contracts and may result in removal from a good payer panel.
 
Coding tip: When a zero follows the decimal point in an ICD-9 code, don't assume that a fourth or fifth digit isn't really necessary. The zero in this position actually provides specific and necessary information about the disease or condition.