Coding to Highest SpecificityICD-9 CM
Why it is important and how it affects you as a physician.JeniSmith, CPC
The Major Issues
Quality Report SuffersIt will not paint an accurate picture of the severity of the illnessesSeverity of illness is a measure of the patient's overall health status reflected by the resources necessary for care and the risk of morbidity and mortality“severity of illness is understated 8%-15% of the time. Mortality is understated 15%-25% of the time.” (For the Record, page 11)Reportingcomorbiditiesand illness severity will help better define quality of care and medical necessity for that care.
The Major Issues Continued
RAC Audits85% of Medicare RAC audit identifiedoverpaymentshave been directly relatedtocoding,determination ofmedicalnecessityand/ora need toenhancedetailed documentationgatheredinsupportof submittedclaims.RAC took back over $900 Million from hospitals (Took 3 Mil. from AGH)More MCC, can lead to increased level of visitIncreases in morbidity, mortality, and length of stay will not correlate with the documented severity of illness which could lead to red flags
Major Issues Continued
Transfer to ICD-10 System InevitableICD-10offers more detailed information and the ability to expand specificityGreaterspecificity and clinical information, which results in:Improvedability to measure health careservicesIncreasedsensitivity when refining grouping and reimbursementmethodologies
How to Code for Specificity
Acode is invalid if it has not been coded tothe fullnumber of digits required for that code.Providerreports the full ICD-9-CMICD-9 codes may have three to five digits depending on their category.Each digit provides important information about the patient's condition.http://www.aafp.org/fpm/990700fm/27.html
ExamplesChronic Kidney Disease (CKD)
250.13, uncontrolled type 1 diabetes withketoacidosis.Choosing the most specific code means coding only what you know to be a fact.Thethree-digit code(in this case, 250) represents thediagnosticcategory.Thefourth digitidentifiescomplications associatedwith diabetesThefifth digitdescribes thetype of diabetes and its level of control.To correctly code an encounter with a patient who has uncontrolled type 1 diabetes complicated byketoacidosis, you should useall five digits.
Patient, follow-up of benign essential hypertension = 401.1 (The fourth digit identifies the disease as benign and thus is the most specific description of your patient's condition)However, patient also has benign hypertensive heart disease, include a fifth digit = 402.10 or 402.11 (depending on the absence or presence, respectively, of congestive heart failure)http://www.aafp.org/fpm/990700fm/27.html
You must always code to the highest number of digits that best describe your patient's conditionPhysicians are legally responsible for the codes selected and submittedto payers.Coding to the highest specificity allows for more accurate report of quality of care and will prepare you for possible RAC audits and the implementation of ICD-10-CM.
Additional Diagnosis to watch
Heart Failure – Systolic or DiastolicCOPD – Need to state acute exacerbationSepsis – If code as 599.0, translates to UTI-Need to state Sepsis due to UTICVA – State with Residual or presenting symptomsAnemia – Chronic, Acute blood loss, iron deficiencyPneumonia – Which BacteriaDM – Need type and whether controlled/uncontrolledMorbid Obesity – Must state BMI, can increase reimbursement by thousands (Already calculated on MAR)