August 2009
The importance of accurate diagnostic coding
Accurate diagnostic coding is a critical component of claim submissions. The diagnosis listed on a claim:
- Establishes the benefit and reimbursement levels for claims processing
- Provides a meaningful profile, helping us collect and analyze our members' medical demographic data
Steps for accurate coding, using a current International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for Physicians manual, include:
- Locate the main term within the diagnostic statement.
- Locate the main term in the Alphabetic Index (Volume 2). Certain conditions can be listed under more than one main term.
- Refer to all notes under the main term.
- Review instructions that appear in a box immediately following the main term.
- Review all modifiers that appear in parentheses next to the main term to determine if they apply.
- Review any of the subterms that are indented beneath the main term.
- Subterms differ from the main term. They provide greater specificity, becoming more specific the further they are indented from the main term.
- Be sure to follow any cross reference instructions.
- Confirm the code selection in the Tabular List (Volume 1).
- Select the appropriate classification in accordance with the diagnosis.
- Use the appropriate "V" code when the primary reason for the encounter was not disease or injury-related.
- Follow all instructional terms in the Tabular List (Volume 1), watching for exclusion terms, notes and fifth-digit instructions that apply to the code number.
- Search the selected code number for instructions, including the category, section and chapter in which the code number is collapsible. The instructional information is often located one or more pages preceding the actual page that includes the code number.
- Code to the highest level of detail. A three-digit ICD-9-CM code can be used only when fourth and fifth digits are not available.
- Coding ill-defined conditions - there are codes available for signs and symptoms (780 - 799.9) that can be used for reporting in lieu of a firm diagnosis. Signs and symptoms should also be coded to the highest level of detail.
- Sequence codes correctly. List the ICD-9-CM code for the diagnosis, condition, problem or other reason for the encounter, which is shown in the medical record as the primary reason for the services provided. List all additional codes that describe any co-existing conditions.
We appreciate your attention to this important component that helps facilitate timely claims processing.