Part B Insider (Multispecialty) Coding Alert

Published on Wed May 07, 2003 PDF

Durable medical equipment suppliers are preparing to play "guess the diagnosis code" with all your capped rental patients.

Come April 1, the durable medical equipment regional carriers will require five-digit ICD-9 codes, where applicable, on all claims. Where an ICD-9 diagnosis requires a fourth or fifth digit, the DME regional carriers will reject claims with three-digit codes, according to Dr. Robert Hoover, medical director of Region D DMERC Cigna.

Thus, suppliers will have to use four digits for thyroiditis, which always starts with 245 but has a fourth digit required to specify a more definite diagnosis. But suppliers will have to use only three digits for kwashior-kor, a nutritional deficiency that is always coded 260. Adding extra digits to three- or four-digit codes will lead to claims being returned as unprocessable, Hoover notes.

"This is a big issue with us, and our systems as it is for providers," Hoover says. "We're working diligently to make this HIPAA-related change as painlessly and with the least amount of anxiety possible." He adds that CMS and the DMERCs are still working on ways to minimize the change's impact on providers.

According to the DMERCs' latest guidance, suppliers must make sure every claim they submit for new and longstanding patients has four or five digit ICD-9 codes where those codes exist, according to a clarification issued by the DMERCs in their spring bulletins. But the Centers for Medicare & Medicaid Services and the DMERCs clarified that suppliers won't need to obtain new or revised certificates of medical necessity for existing patients.

As of April 1, the DMERCs will implement new edits to ensure suppliers use the longest ICD-9 code available. The DMERCs will return as unprocessable claims received on or after Jan. 1 and processed starting April 1 if they lack the most specific codes. Suppliers will just have to correct and resubmit those claims.

Every line on an electronic claim must reference a valid diagnosis code. Paper claims don't need diagnosis codes, but the DMERCs will apply the edits to every claim that has them.

ICD-9 codes are updated, revised and deleted every October, but suppliers will have a grace period every year until Dec. 31 to start using the new versions. The DMERCs point out that any diagnosis code must be supported by the information in the patient's medical record.

Suppliers are forbidden from entering any diagnosis information on CMNs, but they won't have to worry about CMNs that the DMERC systems already accepted in the past.

"It's a relief that we will not be expected to obtain revised CMNs and detailed orders for any code changes," says Paula Koenig with the Association for Indiana Home Medical Equipment Services. "That would have been a nightmare!" But she says it remains unclear how suppliers must document the use on claims of ICD-9 codes that don't match the codes on existing CMNs. "Can we document a verbal confirmation, or should we get something signed by the doctor to assure we do not have difficulties in an audit situation?" asks Koenig, executive vice president with Indianapolis-based Wheelchairs & More.