How You Can Help – What To Code



How You Can Help – What To Code

Complete Diagnostic Coding, not just primary Diagnosis

• Providers must report all diagnoses that impact the patient’s evaluation, care, and treatment including:

o Main reason for visit

o Co-existing acute conditions

o Chronic conditions (such as Atrial fibrillation, CHF, Chronic Renal Failure, Rheumatoid arthritis, Crohn’s disease, Diabetes, COPD/ Asthma, & Cardiomyopathy)

1 Pertinent past conditions

Documentation Retains Reimbursement: The listing of Diagnosis codes is not enough, there must be evaluation. The Medical Record must thoroughly document all conditions evaluated: Evaluative documentation would include statements such as: Stable on Meds, condition worsening –medication adjusted, tests ordered – documentation reviewed, condition improving.

Superbills and Documentation: Checking a box to designate an ICD-9 code on the Superbill does not document the conditions assessed. It must be in the chart notes. Superbills are not a documentation source.

References

•Web Based Training available via CMS Web Site

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–Go to: Providers

–Click on: Physicians

–Search Box: coding

–Click on: ICD9 CM Diagnosis Coding

–Click on: Web Based Training (WBT) for ICD-9 Coding

–Click on: Web/Computer-Based Courses

•Free ICD9 DX Coding web site:

•Superbills – ICE Library sample super bill



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ICD-9-CM 2006 – The Source of Current Codes and Guidelines

Go to nchs/data/icd9/icdguide.pdf for 71 pages of Official Guidelines from CMS

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