A 2002 audit of Medicare claims by the Department of Health and Human Services’ Office of Inspector General (OIG) found that Medicare fee-for-service payments that did not comply with Medicare regulations totaled $13.3 billion in fiscal years 2001 and 2002. Improper payments in 2002 occurred mostly in three areas: medically unnecessary services (57.1 percent), documentation deficiencies (28.6 percent) and miscoding (14.3 percent).
How do you prevent or reduce denials or reduction of payment when claims are adjudicated as “not medically necessary”? Begin by following the ICD-9* diagnosis-coding documentation guidelines:
1. Code to the ultimate specificity. There is a significant difference between 716.90, Arthritis, Type and Site Not Otherwise Specified, and 716.39, Menopausal Arthritis, Multiple Sites-Joints.
2. Use additional codes and underlying disease codes. Many conditions require, by medical-record coding rules, that you use two ICD-9 codes in the appropriate order. For example, 533.30 Peptic Ulcer-Acute and Without Obstruction, and 041.86, Due to Helicobacter Pylori Infection.
3. Use multiple codes to fully describe the encounter. This includes coding any additional co-morbidities and/or signs and symptoms that affect the patient’s current encounter.
4. Choose the appropriate principal diagnosis and properly sequence secondary codes. List first the ICD-9-CM** code for the diagnosis, condition, problem or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. Then list additional codes that describe any co-existing conditions or symptoms.
5. Avoid using .8 and .9 “catch-all” codes. In the ICD-9 system, descriptions and digits are provided for times when physicians lack information about a patient’s exact condition or diagnosis. The codes commonly end in .8 or .9 and are often referred to as catch-all codes. Under Medicare coding guidelines, these codes should be used only when the specific information required to code correctly is unknown or unattainable.
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