Urology Coding Alert

In Medicare, the computer that reads your claims determines quickly whether a procedure is medically necessary by the diagnosis code you link to it. The problem is, carriers may differ about what diagnosis codes support a certain procedure. When you read that one diagnosis may support a procedure in one area of the country, you cant assume that the same holds true in your area.

Compliance experts differ on whether a physician should even see the medical necessity lists, but Laura Siniscalchi, RHIA, CCS, CCS-P, CPC, senior consultant with Deloitte and Touche in Boston, recommends against it. If a urologist knows what diagnosis codes will support a particular procedure, he or she could simply pick a code from that list, providing it was an appropriate diagnosis. However, this would leave out the rest of ICD-9, which might include an even more appropriate (although perhaps nonpayable) diagnosis. Allowing a physician to use carrier lists of approved diagnosis codes is very close to fraud. It is coding a claim to get paid.

A real danger of supplying the physician with the list [of payable diagnosis codes] is that his claim wont be supported by the documentation, Siniscalchi says. Also, not every CPT code is covered by a local medical review policy (LMRP) by every carrier.

The urologist, not the coder, must pick the proper diagnosis. Some urologists say, But what if the one I pick doesnt get the claim paid? A physician who is knowledge-
able in ICD-9 diagnosis codes and in insurance requirements will rarely have this problem.

Dont look to national Medicare policy for guidance on what diagnosis codes constitute medical necessity for a procedure. Check with your carrier for medical necessity codes that support certain procedure codes. The individual carrier assigns the diagnosis codes with input from its Carrier Advisory Group (CAG). National policy delineates the conditions for which payment can be made, but makes no mention of specific diagnosis codes.