Wiki Specificity of ICD-9 coding needed for pathology.

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bbooks

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Greetings. I would appreciate the feedback of you who are more experienced in pathology coding than I am. It has been brought to my attention by my employer that I may be able to improve my efficiency if I spent less time being so specific in my coding.

I work for a good group. I was hired almost 2 years ago. Two people without specific coding training had been doing the coding for over 15 years before I was hired. I was their first certified coder and this is my first coding job. I know that pathology coding is somewhat the odd duck of the coding world. I code mostly surgical path and also some cytology and peripheral blood smears. The feedback has come with my surgical path coding.

Those who have been coding before me have had the mindset of coding accurately enough for the bill to be paid. My coding training has taught me to be as specific as I can. I understand that there is a happy medium somewhere, and I would appreciate your advice. Really does the specificity matter as much for pathology billing as compared to a patient encounter? How do all those codes end up affecting the patient's health record?

Thanks much! I look forward to a lively discussion. :)
 
You must code as acurately as possible. The dx code represents the patient's diagnosis and we must always be correct with that. We cannot code just to get paid if the code stands for a diagnosis the patient does not have, no longer has, or might have.
The procedure code must accurately represent what was performed, and at time this may hit a coverage issue or a medical necessity issue, and again we cannot change the procedure code to something "close" just to get paid.
As far as affecting the patient healt recored, inaccurate or completly false dx codes can have the impact of increasing the patient premiums.
 
I don't mean to imply that it has been suggested I code incorrectly or based on assumptions. I work for a very conscientious group dedicated to quality. Perhaps a couple of examples would be useful.

If I see a breast cancer case and the location of the breast cancer is available in the documentation I have, I would take the time to look up the code specific to the location in the breast. My co-workers might use a general breast cancer code. 174.9 (location unspecified) while I might code something like 174.4.

Second example. A hysterectomy case is done for pelvic pain. I would code for all the pertinent pathological findings, but my co-worker might code for just one of the findings or perhaps just the symptom of pelvic pain.

Note again that they have been coding for this company for over 15 years and they have never had a problem related to ICD-9 coding.
 
I know just what you mean, bbooks. I was told I over code by a superior (who is no longer with this co.) She also said I should use the consistant with as a dx. So glad I stuck with what I know to be correct as a coder. Good luck in your coding.
 
Thanks for the feedback! Having had such little contact with other coders (this being my first coding job and I am the only officially trained coder) it can be challenge understanding my role.

In reference to "consistent with" - I do sometimes code the diagnosis from that phrase, but as you know, there are subtle nuances in the pathologist's microscopic, diagnosis, and any additional comments that may lead one to use that diagnosis or not. There must be enough additional information from the entire report (including the referring provider's clinical information) to support using that as a diagnosis. I don't think it's appropriate to say as a blanket statement that one can always code from "consistent with" - which is what it sounds like you were being told from your previous superior. Padget addresses this in his source.
 
I code for the "consitent with" most of the time, because our pathologists mean that to be their best judgement toward a diagnosis based on the evidence.

We use Dennis Padget's coding manual, and he has said in his manual that you should code for the main diagnosis such as malignancy. However, you do not have to then code for inflammation of the same site, because the referring physician will be spending most of their effort on taking care of the cancer. Even so, code what is relevant to the patient's care and use your best judgement. You do not have to code every little thing such as your hysterectomy example (the most relevant findings), but code enough to justify the CPT code. Always code to the highest specificity though (such as your breast cancer example).

With that being said, ICD 10 is coming, and your attention to detail is going to be an asset. Vague NOS and NEC codes are going to be more frequently denied, especially on things such as your breast cancer scenario. Payers are saying that some things can't necessarily always be determined, but things such as "site specific" can. Therefore, if you don't code for the site specificity, they are more likely to deny.
 
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Being as specific as possible very well could mean the difference between a claim denial and claim reimbursement. If you have a specific location then you should code for that location. Insurance companies tend to frown on the "unknown".
 
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