Issue 5 - April 2004

Denied payment?
Don’t get caught in a truncated-coding trap
By Marty Kotlar, DC

Have you ever been denied payment from an insurance company because your diagnosis was considered “truncated”? What the heck is a truncated diagnosis? And how can you avoid denial because of it?

Truncated means shortened or condensed. Now more than ever, insurance companies are looking at your diagnosis to see if it has been truncated. They are now requiring that your diagnostic codes be reported to the “highest degree of specificity.” The diagnosis that you choose represents your patient’s condition to the insurance company and must be extremely accurate. Code to the highest degree of specificity and to the highest degree of certainty possible:

• Specificity. ICD-9 codes are composed of three, four or five digits. Codes with three digits are considered the “heading” of a category that may be further subdivided by using four- or five-digit codes, which provide greater detail. A three-digit code is to be used only if it cannot be further subdivided.

You must assign a four- or five-digit subcategory to a diagnosis when it is provided. The reason: A code could be considered “invalid” if it has not been coded to the fullest number of digits required.

For example: Schmorl’s Nodes, ICD-9 code 722.3 (a four-digit code), has five-digit codes that better describe the diagnosis by incorporating the location of the nodes, such as 722.31 — Schmorl’s Nodes in the thoracic region or 722.32 — Schmorl’s Nodes in the lumbar region.

• Certainty. During the patient’s initial visit, you may come up with diagnostic codes that you consider “probable,” “suspected” or a “working diagnosis.” Be careful: These conditions should not be coded as though they exist.

Rather, code to the highest degree of certainty for that patient encounter to include signs, symptoms, abnormal diagnostic tests or other reason for the visit. You may also be faced with a situation whereby a diagnosis cannot be established at the time of the initial encounter. It’s okay to take two or more visits before confirming a diagnosis. You’re better off waiting a few visits to submit a claim that has a definitive diagnosis for the patient’s condition.

More recommendations
Here are some general pointers that can help you avoid a denial of payment because of truncated coding:

• Be specific. Try not to use ICD-9 codes that are considered unspecified, not otherwise specified or not elsewhere classified.

• Repeat chronic diagnoses. When treating patients with chronic conditions on an ongoing basis, it is compliant to report the chronic diagnosis as many times as the patient receives treatment for the care of that particular condition(s).

• Test and use the results. If a patient comes in to your office with severe low back pain, severe leg pain, constant leg numbness and foot drop, don’t automatically assume and report disc involvement without a diagnostic test to substantiate it. Just because it “walks and talks” like a herniated disc doesn’t mean it is a herniated disc.

Or, if a patient has pain, numbness and tingling in the thumb, index and middle finger, it doesn’t automatically mean the condition is carpal tunnel syndrome.

Test. Then, code the confirmed or definitive diagnosis documented in the test report.

• Document change. Record functional measurements that change the diagnosis after the initial assessment in such a way to clearly document the patient’s actual progress (or lack thereof).

When the services exceed the expected recovery period as it relates to the reported diagnosis, write chart notes that document progress and give an anticipated prognosis or duration of treatment. Indicate in your notes that the patient still requires treatment. And amend the care plan to include the expected duration and frequency of additional services.

• Be accurate with rehab. You need to be accurate when you utilize certain rehab procedures. For example: If you plan on utilizing manual therapy, on the shoulder (CPT code 97140), a soft tissue diagnosis such as 719.51 (shoulder stiffness) would make sense.

Review your ICD-9 coding approach with your office compliance officer and all billing staff members. u

Marty Kotlar, DC, CHCC is the president of Target Coding Inc. Dr. Kotlar is a Certified Healthcare Compliance Consultant and has been helping chiropractors nationwide become experts at insurance reimbursement for the last 12 years. He could be reached at 800-270-7044, by e-mail, drkotlar@targetcoding.com or through his Web site, www.TargetCoding.com.

Editor's note: Which codes should you be using? Dr. Kotlar provides a list of the most commonly used codes used in chiropractic billing. The list is posted in the BONUS articles on our 50th Anniversary Web site -- www.ChiroEco.com/50.