3. Diagnostic studies: Medical necessity/indication for the testing must be documented in order to submit charges for diagnostic studies. The terms “rule out” and “suspect” don’t completely give coders the reason why a physician suspects the patient might have a condition. Usually, abnormal lab tests, signs, and symptoms will often warrant the need for further investigation, and these are the most crucial indications for testing. Not only is this important for diagnostic studies but also for procedures. Make sure that the interpretation of the test results is clear along with a plan/recommendation(s).
4. Diagnosis codes: Assignment of codes per the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) is the next and most important step after a visit, diagnostic study, and/or procedure. These codes support medical necessity for the services provided, and specificity of the diagnosis code is vital to successful submission and payment of a claim. Signs and symptoms are valid code choices when ruling out a more significant disease/diagnosis because these support medical necessity for a work-up to determine etiology. Comorbidities that impact the provider’s decision making should also be added as additional diagnoses to support the higher level of decision making. Up to 12 diagnosis codes can be assigned to any type of service provided. This also applies to preauthorization of all services, such as lab tests, radiology studies, GI diagnostic studies, and procedures. If specific information is not in the documentation for your staff to access, payers will often deny certain lab and radiology studies, as well as some procedures. There are 71,932 ICD-10-CM codes to choose from, and it is often difficult to find the “specific” code when doing a search in the electronic health record and billing system. Education and training are essential during the orientation sessions prior to active employment, as well as any time the system is upgraded. The providers should be willing to work with the IT representative(s) in the practice to help make the information easier to access. In other words, what “buzz” words would they like included in the description of the ICD-10-CM code in the practice’s list of favorites? For example, Crohn’s disease and ulcerative colitis have over a hundred choices. The choices are based on the location of the disease and whether the disease is without or with complications. If you are going to choose to provide a higher level of E&M service for a patient with Crohn’s disease of the large intestine because of exacerbation of the disease with bleeding, then the appropriate diagnosis code would be one of the following:
- K50.10 Crohn’s disease of large intestine without complications.
- K50.111 Crohn’s disease of large intestine with rectal bleeding.
- K50.112 Crohn’s disease of large intestine with intestinal obstruction.
- K50.113 Crohn’s disease of large intestine with fistula.
- K50.114 Crohn’s disease of large intestine with abscess.
- K50.118 Crohn’s disease of large intestine with other complication.
- K50.119 Crohn’s disease of large intestine with unspecified complications.