CPT codes describe the service you performed and the associated ICD-10 diagnosis codes describe the reason you performed that service. Together these codes tell your patient’s story for today’s visit and help to demonstrate medical necessity. It is important that these codes make sense to the payor. The chances of a denied claim increases when using diagnosis codes that are not coded to the highest specificity possible. Diagnosis codes can identify laterality, location, manifestations, and severity. Take advantage of coding to the highest specificity as supported by your documentation and represents your work.
Sequencing the diagnoses with the service performed is an opportunity that will help to establish medical necessity.
Example:
High-level OV with a diagnosis of the common cold as the only diagnosis or as the primary diagnosis. A LOS 5 office visit is an indicator that you have an extremely sick patient. This coding combination will not make sense to the payor and is at risk of being denied or the level of service being reduced. The first, or primary, diagnosis should be the highest-level diagnosis or the most severe diagnosis for this type of visit.
Associating the diagnoses with the appropriate service performed is another opportunity.
Example:
The 2-year-old presents for their established patient well-child check visit. The pediatrician notices eczema in the creases of the elbows and back of the knees. Based on the patient’s past medical history and family history, the provider diagnoses the patient with flexural eczema. This coding scenario will allow for the well child check and the problem visit to be billed. Associating the diagnoses correctly will be key to getting both services reimbursed.
99392 – Est patient - Well-Child check (1-4 years old)
Primary DX - Z00.121- Encounter for routine child health exam with abnormal findings
Use additional code to identify abnormal findings
Secondary DX - L20.82 – Flexural eczema
99213 – Office Visit – Low Level
Primary DX – L20.82 – flexural eczema
If the diagnoses are not associated with the services correctly, the payor may pay the lowest of the two services and deny the other OR deny both services.
Revenue Cycle Financial Clearance working in conjunction with Coding Education to bring you information to manage the patient experience for all patients at UTMB. We are dedicated to the education and success of all UTMB providers. Please contact The RCO Financial Clearance and Coding Education Team to ask questions or schedule a meeting. We are here to help! Email the Coding Education Team. |