Orthopedic Coding Alert

If the surgeon does not circle a diagnosis, it may be up to you to find one

Don't let an incomplete superbill damage your chances of submitting an accurate claim. If the orthopedist in your office fails to indicate the ICD-9 code for the condition he treated, you should read through his documentation to find which diagnoses you should report.

Open the Notes When You Have to -- and Even When You Don-t

Suppose your physician hands you a superbill with the procedures circled and the diagnosis left blank.

You could ask the physician which diagnosis to report, or you could examine the documentation yourself. -If your office has a policy that includes -coding by abstraction- by certified/qualified coders, then submitting charges based on what is supported (documented) in the note is appropriate,- says Ellie Sclocchini, CPC, consultant with Physician Reimbursement and Compliance Specialists in Mullica Hill, N.J. -The physician should be signing off on these charges as part of your internal policy.-

Some practices choose to review the documentation and compare it to any diagnoses recorded on the superbill, even when they aren't required to. This ensures that the documentation matches the code selection every time.

-I know it is more work, but I always check the superbill against the chart note, and I usually bill the problems listed in the note over the superbill,- says Louise Glynn, office manager at Riverbend Family Medicine in Fuquay-Varina, N.C. -We are on an electronic medical record (EMR) system, so it is easier than reviewing paper charts because with EMR the physician selects the code and the note is very specific.-

When in Doubt, Confirm With the Physician

If you are new at coding diagnoses from the physician's notes, you should double-check your code selections with the doctors until you feel comfortable that you are choosing the right codes. This may depend on the amount of detail your physicians document in their notes or the variety of conditions that your practice evaluates.

Tip: Make sure your office creates a policy in writing that spells out what you should do when you encounter a superbill with no diagnosis listed. Some physicians prefer that you ask them for information, while most others rely on their coders to select an accurate code.

Read on to determine how one coder chooses diagnosis codes based on the surgeon's documentation.