Should Secondary Medical Conditions Be Coded?
A secondary medical condition may influence the course of treatment for a patient. Equally important, therefore, is that this not be overlooked when coding for the services. ICD-10-CM diagnosis codes explain why a service was provided, and billing for IV antibiotics is a good illustration of how coding unrelated conditions that impact the need for the service can improve cash flow. For example, a physician may order IV vancomycin to treat an infection for a patient who has a penicillin allergy. The insurance carrier is likely to question why the least expensive antibiotic wasn’t given and may deny the claim, so including the code Z88.0 (penicillin allergy) would help justify the more expensive bill.
The physician’s note isn’t likely to include a specific explanation of the correlation between the prescribed vancomycin and the penicillin allergy so coders will need to, first, become educated in charge denial risks for their provider. Second, the coder must read the entire note and educate the provider regarding any incomplete documentation. . For the billing manager, it can also be advantageous to review reports by CPT or HCPCS code to see if there are an unusual number of denied charges for any particular code and investigate both the documentation and the diagnosis coding.
Comorbidities can also be significant with coding. A comorbidity, which is a pre-existing condition that affects the treatment a patient receives and/or prolongs the length of a hospital stay, should be coded whenever it pertains to the patient encounter. Also review this article for the M.E.A.T criteria. Some common examples of comorbidities include diabetes, cardiovascular illness, cancer, kidney disease, infectious diseases, and dementia. Coders must be diligent in reviewing notes, and coding/billing managers must be aware of the possibility of missing comorbidity diagnoses as a cause for denied claims.
The value of accurate coding should not be underestimated. Its impact on inpatient revenue cycle management was discussed in a previous article on our blog. One of the most common and challenging reasons for a claim denial is that the service/supply was “not medically necessary.” This denial reason can mean a wide variety of things so it can be difficult to troubleshoot and costly to appeal. However, it suggests a problem with communicating information to payers about why the service was provided so adequate and appropriate documentation and coding, which may include secondary medical conditions, is the most effective remedy.
Sometimes, locating causes for denied claims can be a tricky process because staff is accustomed to assigning ICD-10-CM diagnosis codes based on the provider’s one major diagnosis documented in the medical record and assume the coding is correct if there isn’t a difference. However, the lack of support for necessity of the bill might not be as obvious. For this reason, a review or audit by an external party can be helpful by providing additional perspective and expertise to help with identifying potential problems and determining best practices to ensure accurate and appropriate documentation and coding. Getting claims paid the first time around not only helps maintain steady cash flow but it also reduces administrative costs in appeals work. Keeping a good eye on denials can play a key role in revenue cycle management, and it’s a good investment in the future of your business.