Coding Know-How
I have found that most new doctors are not interested in coding and the claim form. Instead, they delegate coding and even diagnosis to their insurance assistant. They look for the bottom line, “Just get it paid!”
Today’s insurance world demands a partnership between the doctor and their staff to gain reimbursement and survive a peer review audit. You and your staff have to take a team approach to insurance reimbursement.
Staff cannot and should not choose the diagnosis for the patient; that is the doctor's responsibility. Choosing the correct diagnosis could be the make or break point in case reimbursement.
A prime example is with the diagnosis "lumbago." Lumbago is lower back pain. It is worthless as a diagnosis!
Why does the patient have lower back pain? That is the real diagnosis.
Early in your practice, your insurance staff can be one in the same with the front desk or therapy staff. Communication between the doctor and the staff is paramount. Choose a staff member who is organized and has a feel for insurance requirements.
Your staff is an investment in your practice. They should attend reputable, continuing education classes. Most importantly, the doctor should attend the classes with their staff.
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You are so right! After many years working on "both sides of this fence" as a Chiropractic Office Manager, consultant and from inside a management care company, you can't stress enough how important the right DX is..and here's one more...CHANGING THE DX as the patient progresses! I can't tell you the number of time the DX stays the same from beginning to end..."lumbar spine sprain/strain"..and then the doctor complains when the insurer refuses to pay 40 visits!!! Tell the story...completely!
Posted by: Carla Vincent | October 27, 2007 at 03:30 PM
On the flip side..........Carla, you knew I would go there!....I have been rejected from insurance companies such as medicare and other insurance companies for being too specific.
I have 3 examples. Medicare will pay me for LBP when they will not pay me for Lumbar facet syndrome. Certain BC/BS plans will not pay for a diagnosis that states "Lumbar disc syndrome with radiculopathy" but will pay for Lumbar facet syndrome with paresthesia. And finally....I had a referral form a GP, for a patient whose insurance required a referral, and the Dx was "hip pain". Well, just as most patients refer to the SI joint and L5/S1 areas as "hip pain" so too will some MD's who do not perform a thurough physical examination/orthopedic examination. I saw a patient for "hip pain" and diagnosed it correctly with SI jont/Lumbo-sacral sprain/strain and was rejected because that was not the diagnosis for which the patient was referred. I ended up getting paid but the phone calls and paper work to do such were not worth the re-imbursement nor the headache. Should I put the goofy referral diagnosis as the primary diagnosis and then list the actual diagnosis as the second, third....?
Posted by: JD | October 28, 2007 at 03:55 PM
Medicare is weird, though. You have to pick a diagnosis that is on their approved diagnosis list. Facet syndrome is not on their list. If you choose Lumbar DDD (722.52) or sciatica (724.3) you would get paid better.
In my opinion, NEVER put lumbago or cervicalgia. Lumbago sounds like a tropical drink! It is not a diagnosis, but a description of a symptom. Lumbago will get you three visits; sciatica 36 visits with the proper documentation. Cervicalgia is a pain in the neck. It describes my next door neighbor, but will hardly get me paid by Medicare.
Don't forget to change box 14, when changing the diagnosis.
Posted by: Mario Fucinari DC | November 04, 2007 at 01:27 PM
I agree with you 100% on the uselessness of Lumbago........a garbage can diagnosis. You stated my point better when you said "you have to pick a diagnosis that is on their approved diagnosis list". The sad reality still remains, that we need to refer to that list which by definition is affecting our diagnosis is it not? You brought up another excellent point....the diagnosis and how it effects the number of visits we are allowed. With these variables, the "correct" diagnosis has many implications.
Posted by: JD | November 07, 2007 at 10:02 AM
When I said "tell the whole story" I was probably being a bit more specific, based on my position with Graston Technique. I often deal with doctors who have been rejected because they never added a DX outside of what was on their form. They started treating a lumbar spine strain/sprain, then start treating for plantar fasciitis with GT and never add that DX and/or modifier to their coding..and then when they are rejected (and yes, sometimes it is a valid rejection based on the PLAN parameters) and try to appeal they are told "you never indicated you were doing more than the original DX. back to you, JD
Posted by: Carla Vincent | November 09, 2007 at 02:33 PM