Implement this ICD-9 action plan to decide which diagnosis should go first Relying on a computer system to rank diagnoses could mean your claims don’t represent medical necessity. To fix the problem, code based on these ICD9 guidelines.
When faced with multiple outpatient ICD-9 codes, you may not know which one to list first. “Should I enter them in the order the provider lists them, or should I start with the presenting diagnosis?” asks Michelle Zilak in the billing department of Western New York Pediatrics in Orchard Park. Here’s what ICD-9 gurus suggest. List the Most Important Reason First You should first code the main or most serious diagnosis, says Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG -- Children’s Healthcare of Atlanta at Egleston. “The primary diagnosis should be either:
• the primary reason for the encounter or
• the condition with the highest risk of morbidity/ mortality that the physician is addressing at the encounter.” Best practice: The pediatrician can help solve the coding dilemma by indicating the primary diagnosis. But if she doesn’t, “the coder should be able to extract the information from the chart,” Linzer says. Nontrained coders should query the physician as to the primary diagnosis, he says. Choose Definitive Over Presenting Be careful that you don’t assume the primary reason for the encounter is the same as the presenting diagnosis. Do this: Instead of focusing on the presenting problem or chief complaint, look for the pediatrician’s definitive diagnosis.
Here’s how: A child comes in because of fever and ear pain, and the pediatrician finds acute suppurative otitis media. You should first code the definitive diagnosis (382.00, Acute suppurative otitis media without spontaneous rupture of ear drum), not the presenting diagnoses (780.6, Fever; and 388.70, Otalgia, unspecified). Because the ear pain and fever are “inherent” in the diagnosed condition, you should not separately code them, Linzer says.
Code Symptoms in 2 Instances Some circumstances, however, do warrant assigning additional ICD-9 codes for a patient’s symptoms:
1. If the child’s symptoms are not part of the disease process, you should separately code them. A classic example of this involves a child who presents with pneumonia and vomiting. In this case, coding the symptom of vomiting in addition to the pneumonia shows that the child is sicker than if he just had pneumonia, says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. “Listing both ICD-9 codes (such as 486, Pneumonia, organism unspecified and 787.03, Vomiting alone) would potentially support a higher level of E/M code.”
