Drug Administration Services and E/M Visits Billed on Same Day of Service
CPT code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or non-chemotherapy drug infusion code, or therapeutic or diagnostic injection code. Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed in addition to a drug administration, the appropriate E/M CPT code should be reported with the 25 modifier. Documentation should support the level of E/M service
billed. For an E/M service provided on the same day, a different diagnosis is not
required.
Office/Outpatient or Emergency Department Visit on Day of Admission to Nursing Facility
A physician may not be paid for an emergency department visit or an office visit and a comprehensive nursing facility assessment on the same day. The E/M services on the same date provided in sites other than the nursing facility are bundled into the initial nursing facility care code when performed on the same date as the nursing facility admission by the same physician.
Monday, November 28, 2011
Friday, November 25, 2011
Patient seen group practice provider on same day?
Physicians in Group Practice
Physicians of the same specialty in the same group practice must bill and be paid
as a single physician.
If more than one E/M (face-to-face) service is provided on the same day to the
same patient by the same physician or more than one physician in the same
specialty in the same group, only one E/M service may be reported unless the
E/M services are for unrelated problems. (Refer to instructions for use of the 76
modifier.)
Instead of billing separately, the physicians should select a level of service
representative of the combined visits and submit the appropriate code for that
level.
Physicians in different specialties in the same group practice may bill and be paid
without regard to their membership in the same group.
Physicians of the same specialty in the same group practice must bill and be paid
as a single physician.
If more than one E/M (face-to-face) service is provided on the same day to the
same patient by the same physician or more than one physician in the same
specialty in the same group, only one E/M service may be reported unless the
E/M services are for unrelated problems. (Refer to instructions for use of the 76
modifier.)
Instead of billing separately, the physicians should select a level of service
representative of the combined visits and submit the appropriate code for that
level.
Physicians in different specialties in the same group practice may bill and be paid
without regard to their membership in the same group.
Tuesday, November 22, 2011
When can we bill highest level CPT code - 99215, 99205
Use of Highest Levels of E/M Codes
To bill the highest levels of visit codes, the services furnished must meet the
definition of the code (e.g., to bill a Level 5 new patient visit, the history must
meet the CPT’s definition of a comprehensive history).
The comprehensive history must include a review of all the systems and a
complete past (medical and surgical) family and social history obtained at that
visit. In the case of an established patient, it is acceptable for a physician to
review the existing record and update it to reflect only changes in the patient’s
medical, family and social history from the last encounter, but the physician must
review the entire history for it to be considered a comprehensive history.
The comprehensive examination may be a complete single-system exam such
as cardiac, respiratory, psychiatric or a complete multi-system examination
To bill the highest levels of visit codes, the services furnished must meet the
definition of the code (e.g., to bill a Level 5 new patient visit, the history must
meet the CPT’s definition of a comprehensive history).
The comprehensive history must include a review of all the systems and a
complete past (medical and surgical) family and social history obtained at that
visit. In the case of an established patient, it is acceptable for a physician to
review the existing record and update it to reflect only changes in the patient’s
medical, family and social history from the last encounter, but the physician must
review the entire history for it to be considered a comprehensive history.
The comprehensive examination may be a complete single-system exam such
as cardiac, respiratory, psychiatric or a complete multi-system examination
Friday, November 18, 2011
Can we choose E & M level of visit based on Time
Selection of Level of E/M Service Based on Duration of Coordination
of Care and/or Counseling
Time is the key factor in selecting the level of service when counseling and/or
coordination of care dominates (more than 50 percent) the face-to-face physician/
patient encounter or floor time (in the case of inpatient services). In general, the
physician must complete at least two out of three criteria applicable to the type/level of service provided to bill an E/M code. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.
Example:
A cancer patient has had all preliminary studies completed and a medical
decision is made to implement chemotherapy. At an office visit, the
physician discusses the treatment options and subsequent lifestyle effects
of treatment the patient may encounter or is experiencing. The physician
need not complete a history and physical examination to select the level of
service. The time spent in counseling/coordination of care and medical
decision-making will determine the level of service billed.
The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends on the physician service provided.
In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.
The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.
of Care and/or Counseling
Time is the key factor in selecting the level of service when counseling and/or
coordination of care dominates (more than 50 percent) the face-to-face physician/
patient encounter or floor time (in the case of inpatient services). In general, the
physician must complete at least two out of three criteria applicable to the type/level of service provided to bill an E/M code. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.
Example:
A cancer patient has had all preliminary studies completed and a medical
decision is made to implement chemotherapy. At an office visit, the
physician discusses the treatment options and subsequent lifestyle effects
of treatment the patient may encounter or is experiencing. The physician
need not complete a history and physical examination to select the level of
service. The time spent in counseling/coordination of care and medical
decision-making will determine the level of service billed.
The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends on the physician service provided.
In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.
The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.
Thursday, November 17, 2011
HCPCS code J3490 and NDC number
I am not getting paid when I submit HCPCS code J3490 with the drug name and NDC number. Why?
Answer:
HCPCS code J3490 is a non-specific code that should be used only when another 'J' code does not describe the drug being administered (i.e., CMS has not assigned a specific 'J' code to the drug used). The appropriate 'J' code should be used if one has been assigned to the drug. For the drug with no assigned 'J' code, the name, strength of the drug (if applicable) and the actual dosage administered must be indicated on the CMS-1500 form in Block 19 or Block 24 (listed with the procedure code). If the drug is compounded, the invoice/acquisition cost must be included with the description. This would ensure proper adjudication of your claim for J3490.
If the name, strength and dosage administered of the drug are not all listed, the claim will be denied for lack of information necessary to process the claim. At present, Railroad Medicare cannot identify a drug by only the NDC number.
HCPCS code J3490 is a non-specific code that should be used only when another 'J' code does not describe the drug being administered (i.e., CMS has not assigned a specific 'J' code to the drug used). The appropriate 'J' code should be used if one has been assigned to the drug. For the drug with no assigned 'J' code, the name, strength of the drug (if applicable) and the actual dosage administered must be indicated on the CMS-1500 form in Block 19 or Block 24 (listed with the procedure code). If the drug is compounded, the invoice/acquisition cost must be included with the description. This would ensure proper adjudication of your claim for J3490.
If the name, strength and dosage administered of the drug are not all listed, the claim will be denied for lack of information necessary to process the claim. At present, Railroad Medicare cannot identify a drug by only the NDC number.
How should I submit compounded drugs administered via implanted pump?
Answer:
Submit a single, combined line item for all drugs with HCPCS code J3490. Combine the charges for all drugs.
Submit a single, combined line item for all drugs with HCPCS code J3490. Combine the charges for all drugs.
Electronic claims:
- Indicate the name(s) and dose(s) of each drug being submitted in the documentation record
Paper claims:
- Indicate 'compunded drugs, invoice attached' in Item 19 of the CMS-1500 Claim Form
- Abbreviations are acceptable, but must use industry acceptable abbreviations (e.g., 'MS' for morphine sulphate)
- Billed amount must be the invoice price for the compounded drug(s). To indicate this, we suggest using 'INV' next to the price (e.g., INV $250.00).
Tuesday, November 15, 2011
Medical records - Provider signature - Acceptable and unacceptable format - electronic signature
Signature Requirements
Medicare requires a legible identifier for services provided/ordered. The method used must be handwritten or an electronic signature (stamped signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes.
Exception: Facsimile of original written or electronic signatures is acceptable for the certifications of terminal illness for hospice.
Providers using electronic systems should recognize that there is a potential for misuse or abuse with alternate signature methods. Facsimile and hard copies of a physician’s electronic signature must be in the patient’s medical record for the certification of terminal illness for hospice. For example, providers need a system and software products that are protected against modification, etc., and should apply administrative procedures that are adequate and correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information being attested. Physicians should check with their attorneys and malpractice insurers regarding the use of alternative signature methods.
All state licensure and state practice regulations continue to apply. Where state law is more restrictive than Medicare, the state law standard will apply. The signature requirements described here do not assure compliance with Medicare conditions of participation.
Acceptable and Unacceptable Documentation Signatures
As a reminder, the treating physician’s signature must be present in the documentation associated with all services submitted to Medicare. Medicare requires the signature be a legible identifier for the provided/ordered services.
The physician’s signature can be in the form of either a handwritten signature or an electronic signature. Stamped signatures (i.e., rubber stamps) are not acceptable signatures.
The following list provides examples of acceptable electronic signatures:
Chart “Accepted by” with provider’s name.
“Electronically signed by” with provider’s name.
“Verified by” with provider’s name.
“Reviewed by” with provider’s name.
“Released by” with provider’s name.
“Signed by” with provider’s name.
“Signed before import by” with provider’s name.
“Signed: John Smith, M.D.” with provider’s name.
Digitalized signature: Handwritten and scanned into the computer.
“This is an electronically verified report by John Smith, M.D.”
“Authenticated by John Smith, M.D.”
“Authorized by: John Smith, M.D.”
“Digital Signature: John Smith, M.D.”
“Confirmed by” with provider's name.
“Closed by” with provider’s name.
“Finalized by” with provider’s name.
“Electronically approved by” with provider’s name.
Examples of acceptable handwritten signatures:
The handwritten signature must be legible.
The handwritten signature must clearly identify the provider performing the billed services.
Examples of unacceptable signatures:
The legible signature is missing from the documentation.
The signature is illegible.
The signature cannot be verified as that of the performing provider.
The signature is typewritten but not authenticated by either a handwritten
signature or an electronic signature.
The provider’s letterhead does not constitute legible identification.
The provider’s initials do not constitute legible identification.
Medicare requires a legible identifier for services provided/ordered. The method used must be handwritten or an electronic signature (stamped signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes.
Exception: Facsimile of original written or electronic signatures is acceptable for the certifications of terminal illness for hospice.
Providers using electronic systems should recognize that there is a potential for misuse or abuse with alternate signature methods. Facsimile and hard copies of a physician’s electronic signature must be in the patient’s medical record for the certification of terminal illness for hospice. For example, providers need a system and software products that are protected against modification, etc., and should apply administrative procedures that are adequate and correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information being attested. Physicians should check with their attorneys and malpractice insurers regarding the use of alternative signature methods.
All state licensure and state practice regulations continue to apply. Where state law is more restrictive than Medicare, the state law standard will apply. The signature requirements described here do not assure compliance with Medicare conditions of participation.
Acceptable and Unacceptable Documentation Signatures
As a reminder, the treating physician’s signature must be present in the documentation associated with all services submitted to Medicare. Medicare requires the signature be a legible identifier for the provided/ordered services.
The physician’s signature can be in the form of either a handwritten signature or an electronic signature. Stamped signatures (i.e., rubber stamps) are not acceptable signatures.
The following list provides examples of acceptable electronic signatures:
Chart “Accepted by” with provider’s name.
“Electronically signed by” with provider’s name.
“Verified by” with provider’s name.
“Reviewed by” with provider’s name.
“Released by” with provider’s name.
“Signed by” with provider’s name.
“Signed before import by” with provider’s name.
“Signed: John Smith, M.D.” with provider’s name.
Digitalized signature: Handwritten and scanned into the computer.
“This is an electronically verified report by John Smith, M.D.”
“Authenticated by John Smith, M.D.”
“Authorized by: John Smith, M.D.”
“Digital Signature: John Smith, M.D.”
“Confirmed by” with provider's name.
“Closed by” with provider’s name.
“Finalized by” with provider’s name.
“Electronically approved by” with provider’s name.
Examples of acceptable handwritten signatures:
The handwritten signature must be legible.
The handwritten signature must clearly identify the provider performing the billed services.
Examples of unacceptable signatures:
The legible signature is missing from the documentation.
The signature is illegible.
The signature cannot be verified as that of the performing provider.
The signature is typewritten but not authenticated by either a handwritten
signature or an electronic signature.
The provider’s letterhead does not constitute legible identification.
The provider’s initials do not constitute legible identification.
Saturday, November 12, 2011
Choosing primary DX - How to determine
Determining the Appropriate Primary ICD-9-CM Diagnosis Code for Diagnostic
Tests Ordered Due to Signs and/or Symptoms
Confirmed Diagnosis Based on Results of Test:
If the physician has confirmed a diagnosis based on the results of the diagnostic
test, the physician interpreting the test should code that diagnosis. The signs
and/or symptoms that prompted ordering the test may be reported as additional
diagnoses if they are not fully explained or related to the confirmed diagnosis.
Example 1: A surgical specimen is sent to a pathologist with a diagnosis of
“mole.” The pathologist personally reviews the slides made from the
specimen and makes a diagnosis of “malignant melanoma.” The
pathologist should report a diagnosis of “malignant melanoma” as
the primary diagnosis.
Example 2: A patient is referred to a radiologist for an abdominal Computed
Tomography (CT) scan with a diagnosis of abdominal pain. The CT
scan reveals the presence of an abscess. The radiologist should
report a diagnosis of “intra-abdominal abscess.”
Example 3: A patient is referred to a radiologist for a chest X-ray with a
diagnosis of “cough.” The chest X-ray reveals a 3 cm peripheral
pulmonary nodule. The radiologist should report a diagnosis of
“pulmonary nodule” and may sequence “cough” as an additional
diagnosis.
* Signs or Symptoms:
If the diagnostic test did not provide a definitive diagnosis or was normal, the
interpreting physician should code the sign(s) or symptom(s) that prompted the
treating physician to order the study.
Example 1: A patient is referred to a radiologist for a spine X-ray due to
complaints of “back pain.” The radiologist performs the X-ray and
the results are normal. The radiologist should report a diagnosis of
“back pain” since this was the reason for performing the spine X-
ray.
Example 2: A patient is seen in the emergency room for chest pain. An EKG is
normal and the final diagnosis is chest pain due to suspected
Gastroesophageal Reflux Disease (GERD). The patient was told to
follow up with his primary care physician for further evaluation of
the suspected GERD. The primary diagnosis code for the EKG
should be chest pain. Although the EKG was normal, a definitive
cause for the chest pain was not determined.
* Diagnosis Preceded by Words That Indicate Uncertainty:
If the results of the diagnostic test are normal or non-diagnostic and the referring
physician records a diagnosis preceded by words that indicate uncertainty (e.g.,
probable, suspected, questionable, rule out or working), then the interpreting
physician should not code the referring diagnosis. Rather, the interpreting
physician should report the sign(s) or symptom(s) that prompted the study.
Diagnoses labeled as uncertain are considered by the ICD-9-CM coding
guidelines as unconfirmed and should not be reported. This is consistent with the
requirement to code the diagnosis to the highest degree of certainty.
Example:
A patient is referred to a radiologist for a chest X-ray with a
diagnosis of “rule out pneumonia.” The radiologist performs a chest
X-ray and the results are normal. The radiologist should report the
sign(s) or symptom(s) that prompted the test (e.g., cough).
Test Orders
The referring physician is required to provide diagnostic information to the testing entity at the time the test is ordered. The physician who is treating the patient must order all diagnostic tests.
An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. An order may include the following forms of communication:
* A written document signed by the treating physician/practitioner, which is hand-
delivered, mailed or faxed to the testing facility.
* A telephone call by the treating physician/practitioner or his office to the testing facility. Note: If the order is communicated via telephone, both the treating physician/practitioner or his office and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.
Or,
* An electronic mail by the treating physician/practitioner or his office to the testing facility.
Incidental Findings
Incidental findings should never be listed as primary diagnoses. If reported, incidental findings may be reported as secondary diagnoses by the physician interpreting the diagnostic test.
Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms
When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, the testing facility or the physician interpreting the diagnostic test should report the screening code as the primary diagnosis code. Any condition discovered during the screening should be reported as a secondary diagnosis.
Requirements That Certain Tests Must Be Ordered by the Treating Physician
Internet-Only Manual (IOM) 100-08, Chapter 3, Section 3.4.1.1D
All diagnostic X-ray services, diagnostic laboratory services and other diagnostic
services must be ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem.
Tests Ordered Due to Signs and/or Symptoms
Confirmed Diagnosis Based on Results of Test:
If the physician has confirmed a diagnosis based on the results of the diagnostic
test, the physician interpreting the test should code that diagnosis. The signs
and/or symptoms that prompted ordering the test may be reported as additional
diagnoses if they are not fully explained or related to the confirmed diagnosis.
Example 1: A surgical specimen is sent to a pathologist with a diagnosis of
“mole.” The pathologist personally reviews the slides made from the
specimen and makes a diagnosis of “malignant melanoma.” The
pathologist should report a diagnosis of “malignant melanoma” as
the primary diagnosis.
Example 2: A patient is referred to a radiologist for an abdominal Computed
Tomography (CT) scan with a diagnosis of abdominal pain. The CT
scan reveals the presence of an abscess. The radiologist should
report a diagnosis of “intra-abdominal abscess.”
Example 3: A patient is referred to a radiologist for a chest X-ray with a
diagnosis of “cough.” The chest X-ray reveals a 3 cm peripheral
pulmonary nodule. The radiologist should report a diagnosis of
“pulmonary nodule” and may sequence “cough” as an additional
diagnosis.
* Signs or Symptoms:
If the diagnostic test did not provide a definitive diagnosis or was normal, the
interpreting physician should code the sign(s) or symptom(s) that prompted the
treating physician to order the study.
Example 1: A patient is referred to a radiologist for a spine X-ray due to
complaints of “back pain.” The radiologist performs the X-ray and
the results are normal. The radiologist should report a diagnosis of
“back pain” since this was the reason for performing the spine X-
ray.
Example 2: A patient is seen in the emergency room for chest pain. An EKG is
normal and the final diagnosis is chest pain due to suspected
Gastroesophageal Reflux Disease (GERD). The patient was told to
follow up with his primary care physician for further evaluation of
the suspected GERD. The primary diagnosis code for the EKG
should be chest pain. Although the EKG was normal, a definitive
cause for the chest pain was not determined.
* Diagnosis Preceded by Words That Indicate Uncertainty:
If the results of the diagnostic test are normal or non-diagnostic and the referring
physician records a diagnosis preceded by words that indicate uncertainty (e.g.,
probable, suspected, questionable, rule out or working), then the interpreting
physician should not code the referring diagnosis. Rather, the interpreting
physician should report the sign(s) or symptom(s) that prompted the study.
Diagnoses labeled as uncertain are considered by the ICD-9-CM coding
guidelines as unconfirmed and should not be reported. This is consistent with the
requirement to code the diagnosis to the highest degree of certainty.
Example:
A patient is referred to a radiologist for a chest X-ray with a
diagnosis of “rule out pneumonia.” The radiologist performs a chest
X-ray and the results are normal. The radiologist should report the
sign(s) or symptom(s) that prompted the test (e.g., cough).
Test Orders
The referring physician is required to provide diagnostic information to the testing entity at the time the test is ordered. The physician who is treating the patient must order all diagnostic tests.
An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. An order may include the following forms of communication:
* A written document signed by the treating physician/practitioner, which is hand-
delivered, mailed or faxed to the testing facility.
* A telephone call by the treating physician/practitioner or his office to the testing facility. Note: If the order is communicated via telephone, both the treating physician/practitioner or his office and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.
Or,
* An electronic mail by the treating physician/practitioner or his office to the testing facility.
Incidental Findings
Incidental findings should never be listed as primary diagnoses. If reported, incidental findings may be reported as secondary diagnoses by the physician interpreting the diagnostic test.
Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms
When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, the testing facility or the physician interpreting the diagnostic test should report the screening code as the primary diagnosis code. Any condition discovered during the screening should be reported as a secondary diagnosis.
Requirements That Certain Tests Must Be Ordered by the Treating Physician
Internet-Only Manual (IOM) 100-08, Chapter 3, Section 3.4.1.1D
All diagnostic X-ray services, diagnostic laboratory services and other diagnostic
services must be ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem.
Tuesday, November 8, 2011
Rules of DX code in CMS 1500
DIAGNOSIS OVERVIEW
ICD-9-CM Codes
Physicians and Non-Physician Practitioners (NPP) must use the appropriate
diagnosis code or codes to identify symptoms, conditions, problems, complaints
or other reasons for the encounter or visit.
Claims will be returned as unprocessable when the ICD-9-CM code is invalid.
Rules for Reporting Diagnosis Codes
*Use the ICD-9-CM code that describes the patient’s diagnosis, symptom,
complaint, condition or problem. Do not code a suspected diagnosis.
* Use the ICD-9-CM code that is chiefly responsible for the item or service
provided.
* Assign codes to the highest level of specificity. Use the fourth and fifth digits
where applicable.
* Code a chronic condition as often as applicable to the patient’s treatment. Code
all documented conditions that coexist at the time of the visit that require or affect
patient care or treatment. Do not code conditions that no longer exist.
ICD-9-CM Codes and Date of Service
The ICD-9-CM codes must be coded to the highest level of specificity for the date of service, i.e., coding to the fourth or fifth digit. This is a requirement for all physician and NPP claims.
Diagnosis codes must be reported based on the date of service on the claim and not the date the claim is prepared or received.
Updated ICD-9-CM codes are effective each October 1.
ICD-9-CM Codes
Physicians and Non-Physician Practitioners (NPP) must use the appropriate
diagnosis code or codes to identify symptoms, conditions, problems, complaints
or other reasons for the encounter or visit.
Claims will be returned as unprocessable when the ICD-9-CM code is invalid.
Rules for Reporting Diagnosis Codes
*Use the ICD-9-CM code that describes the patient’s diagnosis, symptom,
complaint, condition or problem. Do not code a suspected diagnosis.
* Use the ICD-9-CM code that is chiefly responsible for the item or service
provided.
* Assign codes to the highest level of specificity. Use the fourth and fifth digits
where applicable.
* Code a chronic condition as often as applicable to the patient’s treatment. Code
all documented conditions that coexist at the time of the visit that require or affect
patient care or treatment. Do not code conditions that no longer exist.
ICD-9-CM Codes and Date of Service
The ICD-9-CM codes must be coded to the highest level of specificity for the date of service, i.e., coding to the fourth or fifth digit. This is a requirement for all physician and NPP claims.
Diagnosis codes must be reported based on the date of service on the claim and not the date the claim is prepared or received.
Updated ICD-9-CM codes are effective each October 1.
Medical Billing
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