The ICD.10 diagnosis codes are used to describe the diagnosis, symptom, condition, problem or complaint associated with the treatment of a patient. Diagnosis coding plays a major role in reimbursement and medical billing compliance and should be coded to the highest level of specificity for the visit. The ICD.10 selected for billing is used to establish medical necessity for the service, create a medical billing history for the patient, and it is used as a determinant by insurers for reimbursement. Some insurers may down code or deny services if the ICD.10 code(s) submitted does not support the intensity or frequency of the CPT code billed.
A California medical practice, Beaver Medical Group, recently paid a total of $5,039,180 to resolve allegations that they reported invalid diagnoses to Medicare Advantage plans. Billing invalid diagnosis codes caused the Medicare Advantage Plans to receive inflated payments from Medicare.
Medicare Advantage plans — but not the physicians who care for patients in Medicare Advantage plans — are already paid partially based on a risk-adjusted factor. CMS varies the payment per patient, per month based on the how sick the whole population of patients are. Those payments are based on the diagnosis codes selected and billed by the physician.
The following tips apply to diagnosis coding:
- Code a chronic condition as often as applicable to the patient's treatment.
- Code all documented conditions which coexist at the time of the visit that require or affect patient care or treatment.
- Do not code conditions which no longer exist, however It may be accurate to select a "history of" code.
- If the condition is mentioned in the past medical history but is not addressed at this visit, don't report it.
- If the condition is considered — even if that physician isn't treating it — it should be reported.
- While unspecified diagnosis codes are sometimes appropriate, their use should be the exception, not the rule.