| If the doctor doesn't circle a diagnosis, the onus may | | | | that spells out what you should do when you |
| be on you to find one. Do not let an unfinished superbill | | | | encounter a superbill with no diagnosis listed. Some |
| ruin your chances of submitting a spot-on claim. If the | | | | doctors prefer that you ask them for information, |
| doctor in your office fails to point out to the ICD-9 | | | | whereas most others rely on their coders to choose |
| code for the condition he tended to, you should read | | | | an accurate code. |
| through his documentation to find which diagnoses you | | | | For clues check the notes |
| should go for. | | | | Think about this example of a situation in which the |
| Open the notes when you have to – and even | | | | coder must fill up the blanks when the physician has |
| when you don't have to | | | | not written a diagnosis on the patient's superbill. |
| Imagine your doctor hands you a superbill with the | | | | For instance: The physician's superbill shows a |
| procedures circled and the diagnosis left blank. You | | | | level-three office with a patient wearing a lumbar |
| could ask the doctor which diagnosis to report or you | | | | orthosis. It also shows a date of injury of three days |
| could inspect the documentation yourself. If your office | | | | before the date of service and is missing the diagnosis |
| has a policy that covers "coding by abstraction" by | | | | code. |
| certified and qualified medical coders, then submitting | | | | First step: You refer to the dictation, which reads, "The |
| charges based on what is supported (documented) in | | | | patient happens to be a 13-year-old female being |
| the note is apt, according to Barbara J. Cobuzzi, MBA, | | | | evaluated as a consultation at the request of Dr Jones |
| CPC, CPCH,CPC-P, CENTC, CHCC, with CRN | | | | for lumbar pain. The low back pain began on 12-9-09 |
| Healthcare Solutions in Tinton Falls, N.J. As part of your | | | | when she did splits during cheerleading." The doctor |
| internal policy, the physician should be signing off on | | | | completes the remaining history, review of systems |
| these charges as part of your internal policy. | | | | (ROS), past family and social history (PFSH), and |
| Some practices select to review the documentation | | | | exam. |
| and compare it against any diagnoses recorded on the | | | | Going down through the chart note, you see that the |
| superbill, even when they are not required to. This sees | | | | patient brought an MRI and x-ray with her, which |
| to it that the documentation matches the code | | | | showed a hairline fracture to the patient's third lumbar |
| selection each and every time. | | | | vertebra (L3). |
| Confirm with the physician when in doubt | | | | Under a different heading, the physician has given his |
| If you're new at coding diagnoses from the physician's | | | | assessment, which states: Closed L3 fracture, benign. |
| notes, you should double check your code selections | | | | The next step: When you look up "fracture" in Vol 2 of |
| with the practitioners prior to submitting your claims. | | | | the ICD-9 code book, the most specific body area |
| "Until a medical coder feels at ease with the ICD-9 | | | | listed is "vertebra, lumbar (closed)," which is 805.4 |
| books and the codes used more often in their office, it | | | | (Fracture of vertebral column without mention of spinal |
| is a good idea to run the choices by a clinician," | | | | cord injury; lumbar, closed). |
| according to Suzan Berman, CPC, CEMC, CEDC, | | | | You then turn to Vol 1 and read the information under |
| senior manager of coding & compliance with the | | | | the "fracture of vertebral column" heading to check for |
| Physician Services Division of UPMC in Pittsburgh. | | | | exclusions and see that none apply in this particular |
| You never want to pass on a patient a disease or | | | | case. You do a search under 805.4 to see if by |
| symptom they don't have or one more severe (or | | | | chance the book lists codes for benign or traumatic |
| less) than what they have. This is also beneficial to the | | | | fractures, which it does not. |
| physicians, because if you choose unspecified codes a | | | | To add to it, ICD-9 doesn't instruct you to add a fifth |
| lot, they may learn how to document better the | | | | digit to 805.4. As such, you know that 805.4 is the |
| patient's condition into their notes." | | | | most spot-on code for your physician's visit. |
| Tip: See to it that your office creates a policy in writing | | | | |