Pediatric Coding Alert

The most complete diagnosis code is not always 5 digits If you are submitting CPT codes with three-digit diagnosis codes linked to them, you'd better be sure that the claim is correct, because more payers than ever before are demanding accurate ICD9 coding.

In fact, diagnosis coding is evolving from a choice to a necessity when filing with some carriers - because they are rejecting claims as "medically unnecessary" at a higher rate than they did a few years ago. If you're not taking ICD-9 coding seriously, it's only a matter of time before it affects the practice's bottom line, experts say. Payers Looking at ICD-9 Codes on Claims Before sending out a claim with a three-digit diagnosis code, you should double-check the code, says Victoria Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif. Jackson contends that three-digit diagnosis codes raise the eyebrows of payers because there are very few ICD-9 codes that aren't at least four digits, and all insurance carriers are getting more careful when it comes to diagnosis coding.

"A lot of us didn't pay attention to ICD-9 coding in the past because Medicare was the only carrier that cared if you used the codes," Jackson says. Now, all insurance companies are looking for ICD-9 codes, so coders have to make sure the diagnoses are correctly represented on claims.

No doubt about it, accurate and complete diagnosis coding gets more important each year. And with the Centers for Medicare and Medicaid Services (CMS) demanding immediate implementation of its new ICD-9 codes from now on (see "You Be the Expert" on page 34), it's plain to see that diagnosis coding isn't getting any less urgent.

Read on for advice on how to head off ICD-9 coding troubles before they begin. Take the 2-Question Test To ensure accurate ICD-9 reporting, Margaret Lamb, RHIT, CPC, coding expert in Great Falls, Mont., asks herself two questions before sending out a claim:

1. Do I have a complete code?
2. Do I have the most specific complete code? Why are these things important? If the ICD-9 code is not as complete and specific as carrier rules require, the claim may be rejected for lack of medical necessity, Lamb says. You can check that you have the most complete and specific code when looking up the code in the ICD-9 book - if you know what to look for.

Some Conditions Require 5-Digit Diagnosis Codes There are certain ICD-9 codes that you must carry out to the fifth digit, so you need to know when a fifth digit [...]