Demystifying Medical Codes

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For many doctors, coding, documentation and medical necessity are tedious administrative issues they would rather not have to worry about. But properly coding paperwork helps ensure reception of accurate and timely payments, create a more precise Medicare physician profile and improve continuity of care between providers.

And there is no better time than now to get on board. The current system, ICD9, will be in use until 2012. Beginning in October 2013, the system will change to ICD10, which increases in specificity from 69,000 codes to 140,000.

This is not a scary change, there will just be more specificity,” said Kathryn DeVault, professional practice manager at the American Health Information Management Association. “Building charge slips and cheat sheets just gets more involved.”

Following is a handful of tips from DeVault to correct common coding woes.

Acute renal failure

DeVault said this is the number one issue with nephrologists. Prior to fiscal year 2011, unspecified acute renal failure was a Major CC in the diagnosis-related group reimbursement system. The diagnosis became overused, so it was changed to a Minor CC. One way to ensure proper reimbursement is to make this diagnosis as specific as possible by listing a cause, like acute renal failure due to tubular necrosis.

Chronic kidney disease

There are a number of clinical indicators that point to a patient having a specific stage of renal failure. These indicators may be obvious, but Medicare wants the doctors to spell it out in their documentation. This way, they can be sure patients are getting the correct treatment.

“Doctors have to document what stage patients are in,” DeVault said. “If we don't get that specificity in the documentation, we can't reflect the issue. If we have a patient who is in Stage 4 and we get no stage, we have to assign it to the unspecified code and can't really tell how sick the patient is.”

Urinary tract infections

It is easy to code all urinary tract infections as unspecified. But it is important to be more specific to receive proper reimbursement if there is more to the problem.

If a patient has cystitis or pyelonephritis, which is more difficult to treat than a run-of-the-mill infection, you have to prove medical necessity. 

“If you don't have that documentation, Medicare can only code it to an unspecified code,” DeVault said.

Prostate surgery

A final area where more specificity is typically needed is when a resection of the prostate or a prostatectomy is performed.

DeVault said doctors need to document if a physician needs to remove one or more lymph nodes to determine the stage of prostate cancer. Physicians should also note whether a section of or the entire prostate is removed.

Making changes

DeVault recommends having an office or billing manager take charge of code investigation. They can go through records, find the codes are repeatedly getting denied or not fully reimbursed, and figure out what documentation is missing.

If working in a paper world a simple change like expanding the super bill may be helpful, DeVault said. If the codes listed aren't specific enough, physicians may just be circling the closest choice, like a UTI instead of cystitis.  

“It's a game with Medicare, but my feeling has always been that if we get the appropriate documentation—if we can really get in line with what is wrong with a patient—then the appropriate reimbursement will follow,” DeVault said.

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