Ophthalmology and Optometry Coding Alert

Hint: Medical necessity is not necessarily a top priority If your diagnosis coding fails to support medical necessity for the services and procedures provided, carriers can deny claims outright or may require repayment (along with additional fines or even fraud investigations) at a later date. Even when a procedure or service is medically necessary and appropriate, faulty ICD-9 coding can derail the claim. Here are three tips to help you ace diagnosis coding. 1. Think Accuracy First, Medical Necessity Second In all cases, you should strive to report ICD-9 codes that accurately and completely describe the patient's condition as supported by your documentation. You shouldn't code "rule out," "suspected," "probable" or "questionable" diagnoses. If you don't have a definitive diagnosis, "look for any signs or symptoms that the patient has been having," says Denae M. Merrill, CPC, coder for Covenant MSO in Saginaw, Mich. And never assume that a diagnosis applies or select a code based on your memory of the encounter. Be sure that there is sufficient information in the encounter note to support any ICD-9 codes you assign. Details matter: In the same vein, always be sure that you report a diagnosis to the highest level of specificity available. Including fourth and fifth digits, when available, to any ICD-9 codes you report is incredibly important for both accurate coding and timely payment. The second goal of successful diagnosis coding is to establish medical necessity for any services and procedures the patient receives. Medicare sets the standard for all payers by defining medical necessity as "those services or items reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member." Check off your list: Medicare further qualifies "reasonable and necessary" to mean that a service or procedure is safe and effective, and not experimental or investigational. The procedure must also be appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is: • furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition, or to improve the function of a malformed body member • furnished in a setting appropriate to the patient's medical needs and condition • ordered and furnished by qualified personnel • one that meets, but does not exceed, the patient's medical need • at least as beneficial as an existing and available medically appropriate alternative. Watch for: Many payers will establish guidelines that state explicitly which diagnosis codes they will accept to establish medical necessity for a given CPT or HCPCS procedural code, and you can find these codes in the payers' local coverage determinations (LCDs) for various procedures. Keep [...]