Tactics for Coping With Denials Of Concurrent Care Claims

Avoid denials of concurrent care claims for in-patient consultations by taking advantage of the fifth coding digit to convey the most specific diagnosis possible, says Michael Sullivan, MD, executive director of Tacoma, Wash., Northwest Medical and its infectious disease practice, Infections Limited.

For example, a hospitalized pneumonia patient fails to improve with standard treatment, requiring a consultation with an infectious disease specialist. However, for in-patient care, some insurance companies allow only one doctor per day to bill per ICD-9 code diagnosis for a given patient. Because of this policy, if both physicians billers use the same ICD-9 code for the diagnosis, often only the physician whose claim is sent in first gets paid, and the claim for care provided by the other physician is denied. This is a very big problem for us because I tie up thousands and thousands of dollars challenging something that should be absolutely straightforward, says Larry Hocking, practice manager of a large multi-office New Jersey-based practice, ID Care.

Use the most specific code possible, and code to the highest level, taking full advantage of the fifth coding digit, advises Sullivan. This is a particularly good policy to implement anyway because, as Sullivan notes, Medicare requires the most specific level of coding.

The common belief has often been that more codes justify a higher level of visit. However, being very, very specific can be a better approach, recommends Sullivan. For example, a pneumonia case may initially be diagnosed and coded by using the simplest code, 486 (pneumonia, organism unspecified). However, an infectious disease specialist called in for a consultation will often order laboratory tests to specify which organism is causing the infection and thereby enable the attending physician to provide more targeted antibiotic treatment. Lab results likely will change the diagnosis of simple pneumonia to a four- or five-digit ICD-9 code, such as pneumonia due to staphylococcus (482.4) or pneumonia due to staphylococcus aureus (482.41). Billers should be aware of such a change in diagnosis so that they can reflect it when submitting the claim. Its a matter of physicians working closely with billing staff, says Sullivan.

Using the same code with no complicating factors can also set billers up for problems, Sullivan adds. Often, the infectious disease specialist will find another complicating condition, and billers should make sure to include this. He gives as an example the case of a skin infection, impetigo, on the leg (684), which fails to resolve with standard treatment. After consultation, the infectious disease specialist may discover that the infection has spread into the deep tissue under the skin (cellulitis, 682.6) and even into nearby bone (osteomyelitis, 730.26). In such a case, all three codes should be used to [...]

- Published on 2000-04-01