Ob-Gyn Coding Alert

A common problem in ob/gyn diagnosis coding is the failure to reach the highest possible level of specificity. What I see too often is physicians writing down a general diagnosis, such as abdominal pain or hypertension, and the coder then using the unspecified code, says Deb Lief, CPC, president of the North Texas Chapter of the AAPC and manager of coding compliance for ProMedCo, a practice management firm in Fort Worth, TX. The result is that the practice experiences claim denials, loses money and may be putting itself in jeopardy of losing more money in the future, she says. The solution is in assuring that diagnosis coding is as specific as possible. This is accomplished by understanding the relationship between specificity and reimbursement, always practicing thorough coding processes and creating a complementary partnership between the coder and physician.

How Specificity Affects Reimbursement

Currently, reimbursement is based on CPT procedures and services, not on the diagnosis codes. But the reimbursement for services and procedures depends upon whether credible medical necessity has been established by applying the correct diagnosis codes. Those codes reflect to the payer why the services or procedures were performed. According to Lief, payers are giving more attention than ever to the diagnosis codes. And increasingly, reimbursement is being denied if the ICD-9-CM codes are not specific enough. For example, if you code for a diagnostic laparoscopy (56300), the payer wants to make sure the procedure is justified and will be looking hard for diagnosis codes that do not prove medical necessity. Just coding abdominal pain 789.00 is not enough. You need to be precise about location (upper, lower, left, right quadrant) and list any other symptoms. If the coding is not carried to this level of specificity, payment may be denied or downcoded. This is especially important when trying to show medical necessity in the higher levels of E/M coding. When coding for such problems as PID, menstruation problems, hypertension and diabetes, code selection should reflect precisely everything that is known about the problem (i.e. the specifics of the inflammation for PID).

According to Lief, diagnosis codes are only going to become more important in the future. I see diagnosis-based reimbursement coming in a few years, she says, pointing out that Medicare, HCFA and many commercial carriers are already beginning to keep databases on each physicians code use. In the near future, this data could be used to guide payment, as capitated coverage spreads. If you are not coding to the highest level of specificity, payers will look at your data and may assume that you are not seeing the higher levels or more complicated patients, and will only pay for the level of patients your diagnosis coding reflects. Therefore, how you code now may affect your future reimbursement.

Three Steps Encourage Highest Specificity Coding

You can be sure you are coding to the highest possible level of specificity by always following a sound coding and assessment process. This process includes several steps.

1. Gather complete data. When the coder is translating the encounter form into codes, complete information is needed. Lief points out that in many instances, there is simply not enough information on the encounter form. For example, if the physician has simply written endometriosis on the encounter form, more information is needed. Endometriosis (617) is a nonspecific code and could be denied. You need the data that will help you determine the location of the endometriosis and whether it is a confirmed or rule-out diagnosis. A rule-out diagnosis is important to have in the chart, but it will not justify the procedure or service and it cannot be coded directly. Therefore, the coder will need to seek out more information on the specific symptoms from the patients chart or by asking the physician. Specific diagnosis coding requires clear access to all the necessary information.

Ideally, diagnosis information should come from the physicians clear, concise and specific diagnosis written on the encounter form. But Lief says this kind of detail is the exception in most practices. Instead, she recommends that the encounter form list the common diagnosis codes along with a clear indicator when more specificity is needed. The physician or nurse needs to know which diagnosis codes need more information. Lief suggested using a line after the code to clearly indicate that more digits are needed (ie, 617.___).

2. Use the code with highest specificity. No matter how well the patient data is communicated to the coder, he or she must assure that the right code is being used and that it is being carried to the highest digit possible. This involves not only noting any caution or warning symbols in the ICD-9-CM (some color-coded ICD books use yellow and red), but also having a good working knowledge of the terminology for the services and procedures. For example, if a woman is seen by her obstetrician for varicose veins and deep phlebothrombosis, the coder will have to support the diagnosis codes by gathering enough information to know that the patient is postpartum, that the problem is considered a complication of her recent pregnancy (meaning you cannot use 454.9 and 451.1X) and that the varicosities and clot are in the lower extremities.

The right codes are found under venous complications in pregnancy and puerperium (671 codes), and clearly need more digits. The simple rule is: assign 3-digit codes only if there are no 4-digit codes with that code category; assign 4-digit codes only if there are no fifth-digit subclassifications for that category and assign the fifth-digit subclassification code for those categories where it exists.

In this example, the specific codes to report are 671.04 (varicose veins of legs in pregnancy and the puerperium) and 671.44 (deep phlebothrombosis, postpartum). The fifth digit clarifies that this was a postpartum condition or complication.

While carrying out to the fifth digit is mandatory, Lief cautions that sometimes you just have to use an unspecific code. Thats what theyre there for, she says. But only use them when there is nothing else.

Finally, to make sure that your diagnosis coding is as specific as possible, make sure to have all codes which apply, but refrain from using ones that do not apply. For instance, in the example above, the code V22.0 or V22.1 would not be reported because the encounter changes from normal supervision of pregnancy to pregnancy complicated by varicose veins. Likewise, the code V22.2, pregnancy incidental, would also not be reported because this code indicates that the condition in question is not complicating the pregnancy or puerperium.

3. Run frequent reports. According to Lief, the real evidence of good diagnosis coding can proactively be evaluated by looking at regular code reports. She recommends using a regular process in which, every two months, you use your billing software to generate a report of the top 50 diagnosis codes and top 50 CPT codes used by each physician. This is just what a consultant will do but you can do it yourself, Lief says. Carefully review the reports noting which nonspecific codes are being used and how often. Report this information to physicians and keep track of each report for the purpose of your benchmarking progress and trends.