Oncology & Hematology Coding Alert

If you continually make the same mistakes with oncology-related ICD-9 codes, you could attract audits from Medicare and private carriers. To avoid trouble down the road, you must learn and follow the correct procedures for submitting diagnosis codes. Coding experts offer these six tips for improving your signs and symptoms coding:
  
1. Know carriers' ICD-9 guidelines. You must know federal, state and private-payer diagnosis reporting requirements, says Pat Sevast, consultant with American Express Tax and Business services in Timonium, Md. If you demonstrate to payers that you followed their requirements, you can defend yourself when they look askance at your decisions. Obtain written rule documentation to safeguard your decisions.
 
For instance, you should be aware that beginning Oct. 1, all paper and electronic claims that you submit to Medicare carriers must contain a valid diagnosis code, except for claims submitted by ambulance suppliers, according to a June 6 CMS program memorandum (PM) B-03-045.  
 
The PM states, "Carriers must return as unprocessable paper and electronic claims that do not contain a valid diagnosis code ..." CMS also forbids carriers from "placing invalid or valid" diagnosis codes on claims for practices. (To read the PM, go to the CMS Web site www.cms.gov/manuals/pm_trans/B03045.pdf.)
 
Furthermore, you should submit ICD-9 codes that provide the highest degree of accuracy and completeness. This means that your oncologist should assign the most precise ICD-9 code to a service. You cannot justify a service with a three-digit diagnosis code when carriers require a more specific four-digit code to describe the patient's condition. For example, your oncologist lists 141 (Malignant neoplasm of tongue) instead of 141.0 (Base of tongue) or 141.1 (Dorsal surface of tongue). In this case, your Medicare carrier would deny your claim.
 
You should know your local medical review policies (LMRP) to ensure that you don't submit an unacceptable diagnosis code that will not prove medical necessity for services. Insurers cover some services based on the presence of certain diagnoses that identify medically necessary reasons for providing the service. If you don't supply these covered diagnoses, your carrier will deny your claim as not medically necessary.
 
For example, let's say Wisconsin Physician Service (WPS) Insurance Corporation serves as your Medicare carrier. Your oncologist performs a breast biopsy (19100*, Biopsy of breast; percutaneous, needle core, not using imaging guidance [separate procedure]) and lists diagnosis code 611.72 (Lump or mass in breast), which the insurer has approved as an acceptable code. So, more than likely, WPS will reimburse your practice for the service.
 
But if you attempted to justify 19100 with 174.x (Malignant neoplasm of female breast), which WPS doesn't regard as medically necessary for biopsy, the insurer would deny your claim.
 
You can obtain information about coverage and medical necessity through your LMRP [...]