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Diagnosis reporting requirements

  1. #1
    Default Diagnosis reporting requirements
    Medical Coding Books
    Hello,
    So I have a silly question.
    I have always been told that you are required to report all diagnosis affecting a client that is related to their visit.

    I work in a mental health clinic, and most of our clients have multiple diagnoses. Our software currently only allows for 1 diagnosis code to go out on a claim.

    The kicker is, if a client has 4 diagnoses, the computer automatically selects the diagnosis that has the lowest numerical value. (which is a big problem, in my opinion)

    There is only a way to designate a diagnosis as primary or secondary or rule out, but if there is more than 1 primary dx, the system takes the lower number of the two (i.e., client has 309.81, 300.00, and 296.32, computer chooses 296.32, and 296.32 is the only diagnosis that goes out on the claim).

    My vendor is telling me that as long as 1 primary diagnosis goes out on the claim, the rest of the diagnoses don't matter, which I personally disagree with, as sometimes you cannot determine the severity of a client by a single diagnosis.

    Does anyone have any resources regarding this? I need to supply our vendor with enough information that they will add additional diagnosis slots in the software. I have checked the CMS website and was unable to come up with anything, so I am hoping to find some input here.

    Thanks for your feedback!
    ~Jessica

  2. #2
    Default
    You need new software! CMS is only concerned w/the primary dx, however I agree sometimes its necessary for additional codes (ie. E codes) that are never entered into the primary position. You should DEMAND that you vendor enter at least 4 as there are as many on a standard HCFA form....if they refuse I would shop around for another Vendor...

  3. #3
    Default
    Quote Originally Posted by kalbright View Post
    You need new software! CMS is only concerned w/the primary dx, however I agree sometimes its necessary for additional codes (ie. E codes) that are never entered into the primary position. You should DEMAND that you vendor enter at least 4 as there are as many on a standard HCFA form....if they refuse I would shop around for another Vendor...


    I agree, unfortunately we just switched to this vendor, and I was not included in the choice process ... I was hoping to find some sort of guidelines I can give them and then demand it. Otherwise they feel that I am having them do something that is outside the scope of our contract

  4. #4
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    I took a pretty great Ingenix class- which is now OptumInsight.com. Most of all insurance is based off of Medicare- Proper coding is necessary on Medicare claims because codes are generally used to assist in determining coverage and payment amounts. ICD-9 codes affect the outcome of DRG's, revenues, and all kinds of stuff. I have a website you can give to you vendor because they're clearly mistaken and wrong.

    "Increased attention to code accuracy has occurred both as a result of the application of ICD codes for purposes other than those for which the classifications were originally designed as well as because of the widespread use for making important funding, clinical, and research decisions. Code accuracy, defined as the extent to which the ICD nosologic code reflects the underlying patient's disease, directly impacts the quality of decisions that are based on codes, and therefore code accuracy is of great importance to code users. Accuracy is a complicated issue, however, as it influences each code application differently. Using the codes for reporting case fatality rates in persons hospitalized for influenza, for example, might require a different level of accuracy than using codes as the basis for reimbursing hospitals for providing expensive surgical services to insured persons. Therefore, users of disease classifications, just as users of any measure, must consider the accuracy of the classifications within their unique situations. An appreciation of the measurement context in which disease classifications take place will improve the accuracy of those classifications and will strengthen research and health care decisions based on those classifications."

    "Information must be trustworthy to be used as a valuable resource for the delivery of healthcare.1 Huffman (1994) argues that classifying information through coding of patients’ diagnoses and procedures will make it more useful.2 The International Classification of Diseases (ICD) codes have been used to classify morbidity and mortality information for statistical purposes, administration, epidemiology, and health services research.3 ICD codes are used to track workloads and length of stay, to assess quality of care, to track utilization rates, and to investigate population status and its determinants.4, 5 Regarding the development of diagnosis-related group (DRG)–based systems in a number of countries such as the United States, Canada, Australia, Germany, Japan, and others, the quality of coding is now known as an important factor in reimbursement.6–9"

    Sorry, I'll find my info you lol! I just can't believe that they didn't think it was that important.
    Last edited by BABS37; 01-10-2012 at 02:16 PM. Reason: add on


    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

  5. #5
    Default
    Quote Originally Posted by babierman View Post
    I took a pretty great Ingenix class- which is now OptumInsight.com. Most of all insurance is based off of Medicare- Proper coding is necessary on Medicare claims because codes are generally used to assist in determining coverage and payment amounts. ICD-9 codes affect the outcome of DRG's, revenues, and all kinds of stuff. I have a website you can give to you vendor because they're clearly mistaken and wrong.

    "Increased attention to code accuracy has occurred both as a result of the application of ICD codes for purposes other than those for which the classifications were originally designed as well as because of the widespread use for making important funding, clinical, and research decisions. Code accuracy, defined as the extent to which the ICD nosologic code reflects the underlying patient's disease, directly impacts the quality of decisions that are based on codes, and therefore code accuracy is of great importance to code users. Accuracy is a complicated issue, however, as it influences each code application differently. Using the codes for reporting case fatality rates in persons hospitalized for influenza, for example, might require a different level of accuracy than using codes as the basis for reimbursing hospitals for providing expensive surgical services to insured persons. Therefore, users of disease classifications, just as users of any measure, must consider the accuracy of the classifications within their unique situations. An appreciation of the measurement context in which disease classifications take place will improve the accuracy of those classifications and will strengthen research and health care decisions based on those classifications."

    "Information must be trustworthy to be used as a valuable resource for the delivery of healthcare.1 Huffman (1994) argues that classifying information through coding of patients' diagnoses and procedures will make it more useful.2 The International Classification of Diseases (ICD) codes have been used to classify morbidity and mortality information for statistical purposes, administration, epidemiology, and health services research.3 ICD codes are used to track workloads and length of stay, to assess quality of care, to track utilization rates, and to investigate population status and its determinants.4, 5 Regarding the development of diagnosis-related group (DRG)–based systems in a number of countries such as the United States, Canada, Australia, Germany, Japan, and others, the quality of coding is now known as an important factor in reimbursement.6–9"

    Sorry, I'll find my info you lol! I just can't believe that they didn't think it was that important.
    I would really appreciate that website !! thanks for your insight

  6. #6
    Location
    Louisville, KY
    Posts
    1,101
    Default
    Since you are coding on the provider side, DRGs do not apply. However, you cannot accurately reflect the patient acuity by only reporting a single diagnosis. You have all sorts of issues with the system selecting only the lowest numeric code . . .

    The ICD-9-CM Official Guidelines for Outpatient instruct the coder to select all conditions that are treated or affect medical decision making during the encounter. I would add to that, 5010 (I believe) expands the number of diagnoses codes that can be transmitted to CMS, etc. If that data were not "wanted" by the entity, the expansion would not occur. How is this system going to act in 2013 when I-10 becomes the system, select the lowest alpha?

    I feel for you; this sounds like a really poor selection and it's unfortunate your practice/organization did not involve you in the process. This is illustration to others of what happens when these decisions do not include coders, billers or people with actual end-use expertise in the area affected by the change in software vendor.
    Last edited by kevbshields; 01-11-2012 at 10:17 AM.

  7. #7
    Location
    Concord, NC or Rochester, NY
    Posts
    154
    Default
    Here is a CMS article that will help: http://www.cms.gov/manuals/downloads/clm104c26.pdf

    See page 10 - Item 21 where it states 'Enter up to four diagnoses in priority order'. Therefore CMS is indicating that the primary one must be first - not the one with the lowest value.

  8. #8
    Default
    Quote Originally Posted by mdoyle53 View Post
    Here is a CMS article that will help: http://www.cms.gov/manuals/downloads/clm104c26.pdf

    See page 10 - Item 21 where it states 'Enter up to four diagnoses in priority order'. Therefore CMS is indicating that the primary one must be first - not the one with the lowest value.
    Thank you all so much!

    I finally feel like I have enough documentation to build my case. I really appreciate the comments

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