Medicare Compliance & Reimbursement

Be careful not to put words in your physician's mouth, or risk audit woes. Imagine your physician treats a chronic pain patient,but during the visit your physician isn't able to uncover a definitive diagnosis. While you know that altering or guessing a diagnosis to ensure payment is wrong, there are codes you can choose from to handle the situation. Here's what you need to know: Interpret Doc's Docs For Help Specificity in diagnosis coding is always important,but it is increasingly vital because "third-party payers are establishing more stringent coverage criteria for therapies and procedures and are using automated edits to deny claims based on the lack of a covered diagnosis," says Mary H. McDermott, MBA, CPC, with Johns Hopkins University in Baltimore. "Using a non-specific diagnosis code, which may be 'close' but not exact, may mean you will not be paid for a service due to a Medicare Local Coverage [...]