Coding to the Highest Level of Specificity

Insurance carriers often deny claims for not being coded to the highest level of specificity. As many billers are not coders they often don't understand what has gone wrong or how to fix it.

If a service line is denied for this reason they are saying that the diagnosis code needs to be more specific. Some diagnosis codes are only three or four digits but many are five digits. The diagnosis must be coded to the absolute highest level for that code, meaning the most number of digits for the code being used.

For example, the diagnosis for hypertension begins with 401. However if you submit a cliam with the diagnosis 401 it will be denied. The code 401 requires a 4th digit. 401.0 is malignant essential hypertension. 401.1 is benign essential hypertension. 401.9 is unspecified essential hypertension. So to bill a claim with a diagnosis of hypertension it must be either 401.0, 401.1, or 401.9.

Another example of a diagnosis needing to be billed to a higher level of specificity would be diabetes. 250.0 indicates diabetes however you neeed a 5th digit to specify what type of diabetes. 250.00 is diabetes mellitus type two, 250.01 is diabetes mellitus type one (juvenile type), and 250.02 is diabetes mellitus type one uncontrolled and so on.

As you can see in the above example just putting 250.0 does not indicate specifically what the problem is. Without the fifth digit the claim is lacking enough information to be processed and therefore will be denied.

If you are unsure if the diagnosis is coded to the highest level of specificity you can look it up in an ICD9 code book or on the web. There are several websites with current ICD9 codes available. They will indicate if the code is coded to the highest level.

Some practice management systems have scrubbers that will catch under coded diagnosis and give you a warning. Sometimes the biller may recognize a truncated diagnosis (or a diagnosis requiring an additional digit.)

In either case the biller should go back to the coder or provider and ask them to be more specific with the diagnosis code so the claim can be resubmitted.

Copyright 2009 - Michele Redmond

Alice Scott and her daughter / partner Michele Redmond are co-owners of a medical billing service. They offer an informational website for both physician's offices and the general public looking for information or help with their problems with medical insurance billing. Check out their website for more information, more about important changes now going on in Medical Insurance Billing, or to sign up for their free monthly newsletter.

This post was made using the Auto Blogging Software from WebMagnates.org This line will not appear when posts are made after activating the software to full version.

EM Coding - Do Not Bill High Level E&M Codes Before Reading This

Sicker patients do not always mean higher MDM.

If your physician bills a lot of high-level office visits, he may be in danger of an audit, which may not be a cause of worry if his documentation justifies his code choices.

"Some doctors think that their patients are sicker than others'; as such they feel they are justified using more 99215s, when in fact that may not be the case," according to Crystal S. Reeves, CPC, CPC-H, consultant with Coker Group in Alpharetta, Ga. "The CPT manual outlines the requirements of the evaluation/management codes, there're clinical examples in the back of CPT, and CMS publishes a Table of Risk that can guide you, so use all of those resources to find out whether you are billing properly," she says.

Training is important: If you advise your doctor that he's overbilling the high-level codes and he says, "But all of our patients are in actuality sick," show the doctor CMS's Table of Risk, "which can be an eye opener for doctor," says Reeves.

According to Reeves, when it comes to MDM for high-level evaluation/management services, "look for how many diagnoses or management options the physician is treating. "If a patient presents with a brain tumor and is chemotherapy but is faring well, his condition may eventually be terminal however this visit may not qualify for a level five. However if the patient has COPD, hypertension, degenerative disc disease, pneumonia, and diabetes, there'll be more data to review, which may qualify for a higher MDM level."

You should make diagnosis coding a priority: If your claim does not convey the status or complexity of the condition, an auditor will not be able to infer it, Stephanie L. Fiedler, CPC, ACS-EM, director of revenue management with YAI in New York, N.Y says. "The best option to do this is to report your diagnosis codes to the highest level of specificity."

If a diagnosis code is not listed on your superbill, do a research to find it rather than just using one that you do to list on your encounter form.

"Certain diagnoses may not be listed on a physician's superbill; as such the physician may just circle the closest unspecified code," says Fiedler. For example, a physician might circle the standard controlled diabetes code on a superbill as it is there, "however any time there are renal, peripheral vascular, or ophthalmic complications, those are the ones they have to go back to the coding book for and most of the time, they don't," she says.

"Minus the more specific code, the doctor is not conveying the acuity of what he is doing, so the diagnosis may not support the claim."

Suzanne Leder, M.Phil., CPC, COBGC is a ob-gyn coding [http://www.codingconferences.com/ob_gyn_1209cds.htm] Alert editor for five years and counting. she holds a specialty OB/GYN coding certification. Currently,an Executive Editor at the Coding Institute and has covered topics in cardiology, physical medicine and rehab, gastroenterology, neurology, orthopedics, and otolaryngology.

This post was made using the Auto Blogging Software from WebMagnates.org This line will not appear when posts are made after activating the software to full version.

Coding to the Highest Level of Specificity

Insurance carriers often deny claims for not being coded to the highest level of specificity. As many billers are not coders they often don't understand what has gone wrong or how to fix it.

If a service line is denied for this reason they are saying that the diagnosis code needs to be more specific. Some diagnosis codes are only three or four digits but many are five digits. The diagnosis must be coded to the absolute highest level for that code, meaning the most number of digits for the code being used.

For example, the diagnosis for hypertension begins with 401. However if you submit a cliam with the diagnosis 401 it will be denied. The code 401 requires a 4th digit. 401.0 is malignant essential hypertension. 401.1 is benign essential hypertension. 401.9 is unspecified essential hypertension. So to bill a claim with a diagnosis of hypertension it must be either 401.0, 401.1, or 401.9.

Another example of a diagnosis needing to be billed to a higher level of specificity would be diabetes. 250.0 indicates diabetes however you neeed a 5th digit to specify what type of diabetes. 250.00 is diabetes mellitus type two, 250.01 is diabetes mellitus type one (juvenile type), and 250.02 is diabetes mellitus type one uncontrolled and so on.

As you can see in the above example just putting 250.0 does not indicate specifically what the problem is. Without the fifth digit the claim is lacking enough information to be processed and therefore will be denied.

If you are unsure if the diagnosis is coded to the highest level of specificity you can look it up in an ICD9 code book or on the web. There are several websites with current ICD9 codes available. They will indicate if the code is coded to the highest level.

Some practice management systems have scrubbers that will catch under coded diagnosis and give you a warning. Sometimes the biller may recognize a truncated diagnosis (or a diagnosis requiring an additional digit.)

In either case the biller should go back to the coder or provider and ask them to be more specific with the diagnosis code so the claim can be resubmitted.

Copyright 2009 - Michele Redmond

Alice Scott and her daughter / partner Michele Redmond are co-owners of a medical billing service. They offer an informational website for both physician's offices and the general public looking for information or help with their problems with medical insurance billing. Check out their website for more information, more about important changes now going on in Medical Insurance Billing, or to sign up for their free monthly newsletter.

This post was made using the Auto Blogging Software from WebMagnates.org This line will not appear when posts are made after activating the software to full version.

EM Coding - Do Not Bill High Level E&M Codes Before Reading This

Sicker patients do not always mean higher MDM.

If your physician bills a lot of high-level office visits, he may be in danger of an audit, which may not be a cause of worry if his documentation justifies his code choices.

"Some doctors think that their patients are sicker than others'; as such they feel they are justified using more 99215s, when in fact that may not be the case," according to Crystal S. Reeves, CPC, CPC-H, consultant with Coker Group in Alpharetta, Ga. "The CPT manual outlines the requirements of the evaluation/management codes, there're clinical examples in the back of CPT, and CMS publishes a Table of Risk that can guide you, so use all of those resources to find out whether you are billing properly," she says.

Training is important: If you advise your doctor that he's overbilling the high-level codes and he says, "But all of our patients are in actuality sick," show the doctor CMS's Table of Risk, "which can be an eye opener for doctor," says Reeves.

According to Reeves, when it comes to MDM for high-level evaluation/management services, "look for how many diagnoses or management options the physician is treating. "If a patient presents with a brain tumor and is chemotherapy but is faring well, his condition may eventually be terminal however this visit may not qualify for a level five. However if the patient has COPD, hypertension, degenerative disc disease, pneumonia, and diabetes, there'll be more data to review, which may qualify for a higher MDM level."

You should make diagnosis coding a priority: If your claim does not convey the status or complexity of the condition, an auditor will not be able to infer it, Stephanie L. Fiedler, CPC, ACS-EM, director of revenue management with YAI in New York, N.Y says. "The best option to do this is to report your diagnosis codes to the highest level of specificity."

If a diagnosis code is not listed on your superbill, do a research to find it rather than just using one that you do to list on your encounter form.

"Certain diagnoses may not be listed on a physician's superbill; as such the physician may just circle the closest unspecified code," says Fiedler. For example, a physician might circle the standard controlled diabetes code on a superbill as it is there, "however any time there are renal, peripheral vascular, or ophthalmic complications, those are the ones they have to go back to the coding book for and most of the time, they don't," she says.

"Minus the more specific code, the doctor is not conveying the acuity of what he is doing, so the diagnosis may not support the claim."

Suzanne Leder, M.Phil., CPC, COBGC is a ob-gyn coding [http://www.codingconferences.com/ob_gyn_1209cds.htm] Alert editor for five years and counting. she holds a specialty OB/GYN coding certification. Currently,an Executive Editor at the Coding Institute and has covered topics in cardiology, physical medicine and rehab, gastroenterology, neurology, orthopedics, and otolaryngology.

This post was made using the Auto Blogging Software from WebMagnates.org This line will not appear when posts are made after activating the software to full version.

Coding to the Highest Level of Specificity

Insurance carriers often deny claims for not being coded to the highest level of specificity. As many billers are not coders they often don't understand what has gone wrong or how to fix it.

If a service line is denied for this reason they are saying that the diagnosis code needs to be more specific. Some diagnosis codes are only three or four digits but many are five digits. The diagnosis must be coded to the absolute highest level for that code, meaning the most number of digits for the code being used.

For example, the diagnosis for hypertension begins with 401. However if you submit a cliam with the diagnosis 401 it will be denied. The code 401 requires a 4th digit. 401.0 is malignant essential hypertension. 401.1 is benign essential hypertension. 401.9 is unspecified essential hypertension. So to bill a claim with a diagnosis of hypertension it must be either 401.0, 401.1, or 401.9.

Another example of a diagnosis needing to be billed to a higher level of specificity would be diabetes. 250.0 indicates diabetes however you neeed a 5th digit to specify what type of diabetes. 250.00 is diabetes mellitus type two, 250.01 is diabetes mellitus type one (juvenile type), and 250.02 is diabetes mellitus type one uncontrolled and so on.

As you can see in the above example just putting 250.0 does not indicate specifically what the problem is. Without the fifth digit the claim is lacking enough information to be processed and therefore will be denied.

If you are unsure if the diagnosis is coded to the highest level of specificity you can look it up in an ICD9 code book or on the web. There are several websites with current ICD9 codes available. They will indicate if the code is coded to the highest level.

Some practice management systems have scrubbers that will catch under coded diagnosis and give you a warning. Sometimes the biller may recognize a truncated diagnosis (or a diagnosis requiring an additional digit.)

In either case the biller should go back to the coder or provider and ask them to be more specific with the diagnosis code so the claim can be resubmitted.

Copyright 2009 - Michele Redmond

Alice Scott and her daughter / partner Michele Redmond are co-owners of a medical billing service. They offer an informational website for both physician's offices and the general public looking for information or help with their problems with medical insurance billing. Check out their website for more information, more about important changes now going on in Medical Insurance Billing, or to sign up for their free monthly newsletter.

This post was made using the Auto Blogging Software from WebMagnates.org This line will not appear when posts are made after activating the software to full version.

EM Coding - Do Not Bill High Level E&M Codes Before Reading This

Sicker patients do not always mean higher MDM.

If your physician bills a lot of high-level office visits, he may be in danger of an audit, which may not be a cause of worry if his documentation justifies his code choices.

"Some doctors think that their patients are sicker than others'; as such they feel they are justified using more 99215s, when in fact that may not be the case," according to Crystal S. Reeves, CPC, CPC-H, consultant with Coker Group in Alpharetta, Ga. "The CPT manual outlines the requirements of the evaluation/management codes, there're clinical examples in the back of CPT, and CMS publishes a Table of Risk that can guide you, so use all of those resources to find out whether you are billing properly," she says.

Training is important: If you advise your doctor that he's overbilling the high-level codes and he says, "But all of our patients are in actuality sick," show the doctor CMS's Table of Risk, "which can be an eye opener for doctor," says Reeves.

According to Reeves, when it comes to MDM for high-level evaluation/management services, "look for how many diagnoses or management options the physician is treating. "If a patient presents with a brain tumor and is chemotherapy but is faring well, his condition may eventually be terminal however this visit may not qualify for a level five. However if the patient has COPD, hypertension, degenerative disc disease, pneumonia, and diabetes, there'll be more data to review, which may qualify for a higher MDM level."

You should make diagnosis coding a priority: If your claim does not convey the status or complexity of the condition, an auditor will not be able to infer it, Stephanie L. Fiedler, CPC, ACS-EM, director of revenue management with YAI in New York, N.Y says. "The best option to do this is to report your diagnosis codes to the highest level of specificity."

If a diagnosis code is not listed on your superbill, do a research to find it rather than just using one that you do to list on your encounter form.

"Certain diagnoses may not be listed on a physician's superbill; as such the physician may just circle the closest unspecified code," says Fiedler. For example, a physician might circle the standard controlled diabetes code on a superbill as it is there, "however any time there are renal, peripheral vascular, or ophthalmic complications, those are the ones they have to go back to the coding book for and most of the time, they don't," she says.

"Minus the more specific code, the doctor is not conveying the acuity of what he is doing, so the diagnosis may not support the claim."

Suzanne Leder, M.Phil., CPC, COBGC is a ob-gyn coding [http://www.codingconferences.com/ob_gyn_1209cds.htm] Alert editor for five years and counting. she holds a specialty OB/GYN coding certification. Currently,an Executive Editor at the Coding Institute and has covered topics in cardiology, physical medicine and rehab, gastroenterology, neurology, orthopedics, and otolaryngology.

This post was made using the Auto Blogging Software from WebMagnates.org This line will not appear when posts are made after activating the software to full version.