Primary Care Coding Alert

Question: Recently weve had a lot of claims denied with patients we have diagnosed as depressed. Why is this happening?

Maryland Subscriber

Answer: Unfortunately, more payers are reimbursing only mental-health professionals for claims citing a mental-health disorder as the primary diagnosis. Some family physicians, however, say they get paid when they code the symptoms that prompted the visit and treatment, rather than the diagnosis. Family practices should use caution, however, and ensure that they dont rely on symptom coding inappropriately simply to justify a charge.

One example of how coding might be approached involves a 32-year-old established female patient who schedules an office visit. During the exam, the patient discusses her feelings of being down, and the physician notes that she has exhibited symptoms like insomnia and apathy, and documents these in the chart. He prescribes an antidepressant and schedules a followup in six weeks. The office visit may be coded as a level three (99213), with a diagnosis code of 780.52 (other insomnia), which is in the section of ICD-9 labeled Symptoms, Signs, and Ill-Defined Conditions.

Some coders may attempt to assign 307.42 (persistent disorder of initiating or maintaining sleep) as an alternative. However, this code is in the Mental Disorders section, and any insurer denying payment for a diagnosis of mild depression is likely to deny for 307.42.

Another example involves an elderly patient experiencing periodic rapid heartbeat or difficulty breathing. Because of the patients age, it is likely the physician would conduct a detailed examination (i.e., 99214) to rule out cardiac or pulmonary disorders. Ultimately, the physician treats the patient for anxiety. Rather than citing anxiety as the diagnosis code, however, the family physician may be more successful getting paid by reporting 785.1 (palpitations) or 786.0x (dyspnea and respiratory abnormalities).


Reader questions were answered by Cindy McMahan, CPC, an independent coding consultant based in Albany, Wisc.; Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement consultant and president of Cash Flow Solutions in Lakewood, N.J.; and Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians.