If you continually make the same mistakes with pulmonology-related ICD-9 codes, you could attract audits from Medicare and private carriers. To avoid trouble down the road, you must learn and follow the correct procedures for how to submit diagnosis codes. Here's how:
1. Know carriers' ICD-9 guidelines. You must know federal, state and private-payer diagnosis reporting requirements, says Pat Sevast, consultant with American Express Tax and Business services in Timonium, Md. If you demonstrate to payers that you followed their requirements, you can defend yourself when they look askance at your decisions. Obtain written rule documentation to safeguard your decisions.
For instance, you should be aware that beginning Oct. 1, all paper and electronic claims that you submit to Medicare carriers must contain a valid diagnosis code, except for claims submitted by ambulance suppliers, according to a June 6 CMS program memorandum (PM) B-03-045.
The PM states, "Carriers must return as unprocessable paper and electronic claims that do not contain a valid diagnosis code ..." CMS also forbids carriers from "placing invalid or valid" diagnosis codes on claims for practices. (To read the PM, go to the CMS Web site
www.cms.gov/manuals/pm_trans/B03045.pdf.)
You should submit ICD-9 codes that provide the highest degree of accuracy and completeness. This means that your physician should assign the most precise ICD-9 code to a service. You cannot justify a service with a fourth-digit diagnosis code when carriers require a more specific fifth-digit code to describe the patient's condition. For example, your pulmonologist lists 493.2 (Chronic obstructive asthma), omitting the appropriate fifth digit: 0 (without mention of status asthmatics or acute exacerbation or unspecified), 1 (with status asthmaticus) or 2 (with acute exacerbation). In this case, your Medicare carrier would deny your claim.
In addition, you should know your local medical review policies to ensure that you don't submit an unacceptable diagnosis code that will not prove medical necessity for procedures. Insurers cover some services based on the presence of certain diagnoses that identify medically necessary reasons for providing the service. If you don't supply these covered diagnoses along with the services, your carrier will deny your claim as not medically necessary.
Let's say your carrier is Palmetto Government Benefits Administrators of South Carolina. Your pulmonologist performs a bronchoscopy (31622, Bronchoscopy [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]) to inspect and wash a spot on a patient's lungs after the patient complains of coughing up blood (786.3, Hemoptysis, cough with hemorrhage). Following Palmetto's LMRP, 786.3 is a "medically necessary" reason for performing the bronchoscopy.
If, however, you attempted to justify 31622 with 417.1 (Aneurysm of pulmonary artery), which Palmetto specifies as not justifying a bronchoscopy, your carrier would most likely deny your claim.
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