Diagnosis Coding: Ways to Decode Your Doctor's Notes

If the doctor doesn't circle a diagnosis, the onus may be on you to find one.Do not let an unfinished superbill ruin your chances of submitting a spot-on claim. If the doctor in your office fails to point out to the ICD-9 code for the condition he tended to, you should read through his documentation to find which diagnoses you should go for.

Open the notes when you have to – and even when you don't have to

Imagine your doctor hands you a superbill with the procedures circled and the diagnosis left blank. You could ask the doctor which diagnosis to report or you could inspect the documentation yourself. If your office has a policy that covers "coding by abstraction" by certified and qualified medical coders, then submitting charges based on what is supported (documented) in the note is apt, according to Barbara J. Cobuzzi, MBA, CPC, CPCH,CPC-P, CENTC, CHCC, with CRN Healthcare Solutions in Tinton Falls, N.J. As part of your internal policy, the physician should be signing off on these charges as part of your internal policy.

Some practices select to review the documentation and compare it against any diagnoses recorded on the superbill, even when they are not required to. This sees to it that the documentation matches the code selection each and every time.

Confirm with the physician when in doubt

If you're new at coding diagnoses from the physician's notes, you should double check your code selections with the practitioners prior to submitting your claims.

"Until a medical coder feels at ease with the ICD-9 books and the codes used more often in their office, it is a good idea to run the choices by a clinician," according to Suzan Berman, CPC, CEMC, CEDC, senior manager of coding & compliance with the Physician Services Division of UPMC in Pittsburgh.

You never want to pass on a patient a disease or symptom they don't have or one more severe (or less) than what they have. This is also beneficial to the physicians, because if you choose unspecified codes a lot, they may learn how to document better the patient's condition into their notes."

Tip: See to it that your office creates a policy in writing that spells out what you should do when you encounter a superbill with no diagnosis listed. Some doctors prefer that you ask them for information, whereas most others rely on their coders to choose an accurate code.

For clues check the notes

Think about this example of a situation in which the coder must fill up the blanks when the physician has not written a diagnosis on the patient's superbill.

For instance: The physician's superbill shows a level-three office with a patient wearing a lumbar orthosis. It also shows a date of injury of three days before the date of service and is missing the diagnosis code.

First step: You refer to the dictation, which reads, "The patient happens to be a 13-year-old female being evaluated as a consultation at the request of Dr Jones for lumbar pain. The low back pain began on 12-9-09 when she did splits during cheerleading." The doctor completes the remaining history, review of systems (ROS), past family and social history (PFSH), and exam.

Going down through the chart note, you see that the patient brought an MRI and x-ray with her, which showed a hairline fracture to the patient's third lumbar vertebra (L3).

Under a different heading, the physician has given his assessment, which states: Closed L3 fracture, benign.

The next step: When you look up "fracture" in Vol 2 of the ICD-9 code book , the most specific body area listed is "vertebra, lumbar (closed)," which is 805.4 (Fracture of vertebral column without mention of spinal cord injury; lumbar, closed).

You then turn to Vol 1 and read the information under the "fracture of vertebral column" heading to check for exclusions and see that none apply in this particular case. You do a search under 805.4 to see if by chance the book lists codes for benign or traumatic fractures, which it does not.

To add to it, ICD-9 doesn't instruct you to add a fifth digit to 805.4. As such, you know that 805.4 is the most spot-on code for your physician's visit.