Part B Insider (Multispecialty) Coding Alert

Published on Fri Jul 25, 2003 PDF

Learn to Avoid Denials From Stale ICD-9 Codes

You may know your patients inside and out, but you still have to take a fresh look every time they walk in the door.

Otherwise, you'll end up with dead-end diagnoses that don't capture what's happening with the patient now. It doesn't matter what complaint a patient has come in for in the past - if that condition doesn't relate to the latest service the patient receives, you'll be in for denials.

Many practices will stereotype a patient based on his or her usual diagnosis, such as hypertension, says consultant Gail Lorenzen with the Sage Group in Newbury Park, Calif. "They may even refer to someone as 'the hypertension person who's coming in.'" Not only does this stigmatize the patient, it may cause the carriers to shoot down your claims.

Many practice management systems will automatically print out the last ICD9 Codes a patient had on a previous visit, says Elizabeth Woodcock with Physician Practice Inc. in Atlanta. Then the physician or other clinician can just circle that code to approve it again, and "boom, you're on to the next patient." If this is happening, you may have to disable that feature of your software.

Most practices that have this problem fix it once they've been audited, Woodcock says.

Part of the problem is that it's often a nightmare to synthesize a single ICD-9 code from a physician's narrative diagnosis, says one coder in Nashville, Tenn. "They get carried away with the narrative, and it's hard to pick out exactly what's the right diagnosis codes." The only way to solve this issue is to talk to physicians about the necessity of selecting a single number that sums up the patient's problem.

The billing people need to be on alert to catch claims with recycled diagnosis codes that don't fit the latest incident, says consultant Lee E. Cavanaugh with Cavanaugh Michaels in Mechanicsburg, Penn. Coders should send these claims back to the physician to get a more accurate diagnosis.

"They should make that as painless as possible for the doctor" by coming up with a  few options, Cavanaugh adds. List a number of ICD-9 codes that could apply to this patient, so the doctor may only have to choose the last digit of the code to assign the severity. Because the differences between a number of five-digit ICD-9 codes may depend on subtle differences in acuteness of illness, it's important to obtain the physician's judgment.

Everything should be set up to make it easy for both the physician and the billing staff to choose a proper diagnosis, Cavanaugh says.