Q: I am a physician who works in a hospital-owned outpatient wound care department (HOPD). Why must I document the specific diagnosis code that pertains to each patient visit?
A: Diagnosis codes describe diagnoses, signs, symptoms, chronic and acute problems, and conditions. The physician is chiefly responsible for describing "what" and "why" each service was performed/provided on each patient visit. If the Medicare contractor(s) that process(es) the HOPD's claims has issued a local coverage determination or if Medicare has issued a national coverage determination that pertains to the work performed, the physician should print that policy from the Medicare Web site: http://www.cms.hhs.gov/mcd and note the diagnosis code(s) that are covered/not covered. If the patient's diagnosis code that you document does not match the diagnosis codes that Medicare covers for that service/procedure/product, the claims submitted by the HOPD and the physician will be denied. Therefore, proper documentation benefits the patient, the provider, the HOPD, and the payer.
Q: I often use unspecified diagnosis codes because I am busy. Is this a good practice?
A: The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is a statistical classification system that arranges diseases and injuries into groups according to established criteria. Most ICD-9-CM codes are numeric and consist of 3, 4, or 5 numbers and a description. The unspecified codes do not justify the medical necessity for most work performed. They are designated by the following abbreviations:
* NOS: not otherwise specified. It is equivalent to unspecified. The abbreviation refers to a lack of sufficient detail in the statement of diagnosis to be able to assign it to a more specific subdivision within the classification.
* NEC: not elsewhere classified. It is used with ill-defined terms to alert the coder that a specified form of the condition is classified differently. The category number for the term including NEC is to be used only when the coder lacks the information necessary to code the term to a more specific category.
Clinicians owe it to themselves, the HOPD, and the patient to take the time to identify the specific codes that pertain to the diagnoses of patients.
Q: Why do HOPD audits often show that different ICD-9-CM diagnosis codes appear on the submitted claim than the ICD-9 codes that the physician selected on the charge sheets?
A: One or more problems may be occurring:
* The hospital coders may be changing the ICD-9-CM code because the documentation does not support the code that was selected.
* The patient's chart may not be going to the coding department before the claim is submitted; in that case, the diagnosis recorded at the time of scheduling/registration may be the diagnosis that appears on the claim. If this is happening in your facility, you should do everything possible to improve that process.
For example, a new HOPD and its physicians recently experienced multiple denials on all the applications of several brands of dermal substitutes. Of course, they jumped to the conclusion that the products were not covered. Upon further investigation, they learned that all the patients had diabetes. During the registration process, diabetes was listed as the primary diagnosis. The physician's diagnosis of a decubitus ulcer, heel, was documented in the patient's medical record but was not captured in the billing system. Therefore, the payer denied the application of the dermal substitute because that procedure is not indicated for the treatment of diabetes.
Every HOPD should audit its process for this serious flaw.
Q: I heard that there are many proposed changes for the 2009 ICD-9-CM diagnosis codes, including specific changes to the decubitus ulcer codes. How can physicians learn about the proposed changes to the ICD-9-CM diagnosis codes, and when is the effective date for use of the new ICD-9-CM diagnosis codes?
A: The draft of the 2009 inpatient prospective payment system (IPPS) was published in the April 30, 2008, Federal Register. That document lists the preliminary ICD-9-CM diagnosis codes proposed by the National Center for Health Statistics. Once the Centers for Medicare & Medicaid Services review the public comments and publish the 2009 IPPS Final Rule in August 2008, the final list of ICD-9-CM diagnosis codes will be available online. In addition, all the major publishers of coding books will then release their 2009 ICD-9-CM books.
All physicians, podiatrists, nonphysician practitioners, and HOPDs should purchase a new ICD-9-CM book every year. Because a record number of new, changed, and deleted ICD-9-CM diagnosis codes are expected to be announced, clinicians should consider ordering a personal copy of the 2009 ICD-9-CM book now. The book will clearly identify the new, revised, and changed diagnosis codes. Once practitioners identify all the changes that pertain to their specialty, it is important to update charge sheets and the electronic health record system.
Wound care providers should pay particular attention to the proposed decubitus ulcer ICD-9-CM diagnosis codes. The descriptions for the 2008 ICD-9-CM codes 707.00 to 707.09 have been revised: the descriptor "decubitus" ulcer has changed to "pressure" ulcer. In addition, 5 new ICD-9-CM pressure ulcer codes have been proposed: 707.20 to 707.24. Table 1 shows a comparison of the 2008 and the proposed 2009 ICD-9-CM diagnosis codes and their descriptions.
The new ICD-9-CM diagnosis codes will be effective on October 1, 2008. There is no grace period for transition to the new codes. In fact, the use of incorrect diagnosis codes after October 1, 2008, can result in denied claims. Therefore, physicians, podiatrists, nonphysician practitioners, and HOPDs must begin planning how they will include the ICD-9-CM diagnosis code changes into their documentation for medical necessity of services, procedures, products, and equipment provided to patients.
Q: When a patient with multiple diagnoses presents to the HOPD, what diagnosis code should be listed first on the claim form?
A: In HOPDs, the first-listed diagnosis code on the claim form should be the one that chiefly identifies the diagnosis, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. If other diagnosis codes describe documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management, list those codes in descending order according to importance. Do not code conditions that were previously treated and no longer exist.
To match their documentation, physicians should also remember to select diagnosis codes at the highest level of specificity. A 3-digit code is to be used only if it is not further subdivided. Where fourth-digit subcategories and/or fifth-digit subclassifications are provided, they must be assigned.
Note: An ICD-9-CM code is invalid if it has not been coded to the full number of digits required for that code.