Pediatric Coding Alert

ICD-9 code overlap and unspecified code default slow claims processing.

Do you assume that since the pediatrician is supposed to select the diagnoses, the coder can turn a blind eye to ICD-9 reporting? Think again: The coder can be involved in these capacities.

Role 1: Check for Inherent, Nonincluded Dxs

Coding is a team process, recommends Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. The physician must select the diagnosis and procedure code. The coding team ideally checks for appropriate coding for services, procedures, and diagnosis links.

Catch: The coder must be able to decipher terms.Otherwise, she could green-light a claim suffering from ICD-9 code overlap.

Example: A superbill has 81000 circled for U/A w/micro with diagnosis of headache (784.0), as well as dysuria (788.1). Should the claim contain both ICD-9 codes?

The additional diagnosis of dysuria (788.1) is included, Tuck says. Dysuria, painful urination, is not inherent in the headache (784.0) diagnosis.

On the CMS-1500 form, the coder would link 81000 (Urinalysis, by dip stick or tablet reagent for bilirubin,glucose, hemoglobin, ketones, leukocytes, nirite, pH,protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy) to 788.1. The dysuria diagnosis supports the medical necessity for the urinalysis. The headache diagnosis would be linked to the E/M (such as 99201-99215, Office or Other Outpatient Service).

Role 2: Verify Diagnostic Specificity

Coders will be auditors in the future, predicts Deborah Grider, CPC, CPC-H, CPC-C, CCS-P, EMS, RMA, president of Medical Professionals in Indianapolis. If a physician does his own coding, the coder checks to make sure the documentation supports the codes and the claim gets paid quickly.

When reviewing charts, the coder should check for diagnostic specificity. More and more payers are looking at unspecified codes to determine if they meet medical necessity for level 4 and 5, reports Lynn A. Brown, CPC, director of physician coding and reimbursement at Childrens Health System in Birmingham, Ala.