Primary Care Coding Alert

Correct use of diagnosis codes is crucial to any family practice offices reimbursement. According to Medicare, countless claims each year are rejected as unprocessable for two specific reasons:

Coders do not code to the highest order of
specificity, or
Coders do not assign the fourth or fifth digits
accurately.

Medicare has long made it clear that truncated ICD-9-CM codes codes reported with too few digits will be rejected. Nonetheless, many coders are still not coding to the highest order of specificity, says Susan Garrison, CPC, CPC-H, MPC, CPAR, MCS, president of the American Academy of Professional Coders national advisory board and a senior manager with 3M HIS Consulting Services, which provides coding, reimbursement and management support to physicians and practices in the Atlanta area.

In addition, coders often fail to follow the ICD-9-CM basic coding guidelines for outpatient and physician services, which state that professionals should code to the highest degree of certainty for each encounter. Some coders, however, make the mistake of assuming that this means every diagnostic code should have five digits, points out Garnet Dunston, CPC, MPC, president and CEO of the coding services firm Dunston Enterprises Inc., in Phoenix, and past secretary for the American Academy of Professional Coders national advisory board. They will add a decimal point to a three-digit code, and then attach one or two zeroes. This is just as inaccurate as truncating a code that does require more digits.

Either error will cost a practice time and money, Dunston says. Medicare and many other third-party payers consider incomplete or inaccurate codes invalid. This will nearly always result in additional denials, correspondence and payment delays.

To minimize errors made in diagnostic coding, experts offer the following three tips:

1. Recognize That Three-digit Codes are Rare

If family practice coders find themselves assigning three-digit codes frequently, they need to review their ICD-9-CM manual, Dunston says. There are truly very few three-digit codes that may be used legitimately. If a coder is assigning three digit codes thinking this is correct, it is time for a refresher course in diagnosis coding.

As a matter of fact, there are currently about 13,000 ICD-9-CM codes of which, only about 100 appear as three-digit codes that do not need additional digits. Examples include 430 (subarachnoid hemorrhage) and 431 (intracerebral hemorrhage).

By the same token, Dunston warns, if coders have legitimate reason to report a three-digit code, they should not shy away from it. Because it is rare, some coders may worry about assigning one of these codes. In fact, they may add a decimal and attach one or two zeros just to be safe. But, this will result in denials.

Editors note: In some instances, family physicians [...]