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Pulmonology Coding Alert

6 Expert Tips to Boost Your ICD-9 Coding Accuracy

Published on Thu Aug 14, 2003

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.

You can obtain information about coverage and medical necessity through your LMRP at the Web site http://www.cms.hhs.gov/mcd. Also, remember that carriers don't attach a policy to every service, but when they do, you want to be familiar with the requirements.

2. Always base coding on medical record documentation. You should be fanatical about reviewing documentation to ensure that records support the diagnosis codes you're reporting, Sevast says. Remember, however, that only pulmonologists should select diagnosis codes for claims unless you are a certified professional coder (CPC) and your physician has given you the responsibility to abstract the records.

3. Run system reports to discover claims with invalid codes. Make sure that you keep up with the latest ICD-9 changes, says Catherine Brink, CMM, CPC, president of Health Care Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J. CMS and other carriers will reject your claims if you have not implemented the coding changes.

For example, as of Oct. 1, CMS will delete V04.8 (Need for prophylactic vaccination and inoculation against certain viral diseases, influenza) and replace it with V04.81 (Need for prophylactic vaccination and inoculation, influenza), V04.82 (... respiratory synctial virus [RSV]) and V04.89 (... other viral diseases). Medicare provides you with a deadline of Jan. 1, 2004, to stop using V04.8. And if you submit any V04.8 claims after Jan. 1 instead of V04.8x, you'll face denials from Medicare for omitting the fifth digit.

You cannot alter existing ICD-9 coding or documentation to match coding updates, Brink says.

4. Avoid defaulting to the "unspecified" code. When your pulmonologist provides you with a code that requires a fourth or fifth digit, don't default to an unspecified code. For example, your physician reports a patient's condition as 477 (Allergic rhinitis), and you assign the digit that represents "unspecified" - which may not justify medical necessity in payers' eyes. Let's say you use 477.9 (...cause unspecified), and do not seek out the most appropriate, specific condition, which could be either 477.0 (...due to pollen) or 477.8 (...due to other allergen).

5. Don't code on assumption. If you see that your pulmonologist performs a specific treatment on a patient or prescribes certain medication, you may be tempted to assume that "a patient with that medication must have this diagnosis," Sevast says. Then when you review your pulmonologist's diagnosis choices, you may want to substitute them for your own choices. Suppose your pulmonologist treats a patient with a chronic respiratory condition from prolonged exposure to chemicals. Your physician reports the diagnosis as 506.9 (Unspecified respiratory conditions due to fumes and vapors). But you worry that this diagnosis does not accurately reflect the patient's condition, so you report 506.4 (Chronic respiratory conditions due to fumes and vapors) instead.

Don't. Coders should base their decisions on existing documentation, Sevast says. Review the patient's symptoms and the possible code selection with your pulmonologist both to describe appropriately the patient's true condition and to educate your physician on the choices the ICD-9 book offers.

Also, you shouldn't base codes on assumptions even to rule out possible and suspected conditions when your pulmonologist has not definitively diagnosed the condition. If you assign a specific diagnosis based on assumption, it could potentially lead to diagnosing a patient with a condition he or she doesn't have, which may result in the loss of insurance coverage or an increase in premiums.

6. Never alter documentation. Even if you think your pulmonologist made a mistake or if you have a question concerning the documentation, always consult with your physician before you change anything. Your pulmonologist's chart is a legal document. Thus your physician assumes responsibility for amending his documentation. If the chart needs changes, your pulmonologist should make the appropriate adjustments and follow the current legal standards of medical practice.

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