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Why Diagnostic Coding Is Crucial for

Medical Practices
Simply put, diagnostic coding is used in the healthcare
industry to classify and organie different categories of
diseases, disorders and symptoms! "his type of coding is
crucial for medical practices to pro#ide healthcare
services to patients and at the same time ma$e them more
managea%le for practices! &iagnosis codes also ser#e as a
communication channel %et'een physicians and insurance
agencies! In case of fee-for-
ser#ice model, physician
ser#ices are paid on the
%asis of fee associated 'ith
rele#ant procedural codes
()*" or +)*)S, su%mitted
in the claim form! +o'e#er,
the diagnosis codes support
the medical necessity of a
particular ser#ice and clarify 'hy such a ser#ice 'as
performed! "he payers may deny the claims if they find no
medical necessity 'ith the ser#ice!
-.perts suggest se#eral reasons 'hy diagnosis coding has
so much importance in the health care industry!
Coding for Acuity of Patients /edicare plans pay
the claims partially on the %asis of a ris$ ad0ustment
factor and )/S #aries the payment per patient, per
month according to ho' sic$ the 'hole group of
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patients are! Se#eral medical practice groups also ha#e
this type of ad0ustment 'ith pri#ate insurance
companies! 1eim%ursement %y 2ccounta%le )are
organiations is partly %ased on a determination of the
acuity of their patient population! "his means that at
the end of the contract year, some insurance contracts
pay a higher rate to systems3practices that care for
sic$er patients! In all cases, the insurers determine the
acuity of a group of patients on the %asis of age3gender
distri%ution and %y the diagnosis code on claim forms!
Code for the Highest Level of Specificity It is #ery
important to specify the patient4s symptom, condition
or complaint clearly! It is also re5uired to use a sign or
symptom for outpatient ser#ices if the diagnosis is not
$no'n, instead of 6rule out4 or 6possi%le4! &iagnosis
needs highest le#el of specificity! 7nspecified
diagnosis can4t 0ustify the medical necessity of a
particular ser#ice and ma$es the payers deny your
medical claims! "his 'ill also hamper effecti#e
disease management and research efforts! I)&-9 code
system pro#ides separate codes for specific conditions!
8et4s see this 'ith the e.ample of dia%etes mellitus!
2!" &ia%etes mellitus
2!#2" &ia%etes 'ith hyperosmolarity
2!#2!" &ia%etes 'ith hyperosmolarity,
type II or unspecified type, not stated as
uncontrolled
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2!#2$" &ia%etes 'ith hyperosmolarity,
type I 90u#enile type:, not stated as
uncontrolled
2!#22" &ia%etes 'ith hyperosmolarity,
type II or unspecified type, uncontrolled
2!#2%" &ia%etes 'ith hyperosmolarity, type
I 90u#enile type:, uncontrolled
+o'e#er, a ne' diagnosis code system is e.pected to %e
introduced in 201;, 'hich 'ould loo$ for higher specificity
than I)&-9 (e.ample gi#en %elo',!
&$$" "ype 2 dia%etes mellitus
&$$#!" "ype 2 dia%etes mellitus 'ith
hyperosmolarity
&$$#!!" "ype 2 dia%etes mellitus 'ith
hyperosmolarity, 'ithout non$etotic
hyperglycemic-hyperosmolar coma (<=++),
&$$#!$" "ype 2 dia%etes mellitus 'ith
hyperosmolarity, 'ith coma
'eport Chronic Conditions If a patient #isits the
hospital for the same condition multiple times, the
ser#ices rendered should %e reported! "he conditions
that co-e.ist during the #isit that re5uire or affect
patient care should %e documented 'hile it is not
re5uired to report the condition no longer e.ists! If the
condition is mentioned in the past medical history, %ut
not addressed during the #isit, then it should not %e
reported on the claim! In order to report all this
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scenarios in the correct manner, accurate codes are
indispensa%le!
It is al'ays crucial for physicians to determine the proper
care, appropriate tests and effecti#e treatment for their
patients! &iagnosis coding ena%les them to esta%lish
standard treatment for each diagnosis! "he codes specify
particular symptoms (for e.ample, 'hite %lood counts, in
detail to standardie the treatment!
(ips to I)prove the Accuracy of ICD*+ Codes
"he 2merican >oard of ?amily /edicine conducted a
study in#ol#ing 600 physicians in 2009 and 2010 'hich
re#ealed fatigue and a%dominal pain as the t'o most
common symptoms misdiagnosed! In order to eliminate
misdiagnosis and ensure smooth %illing process, you need
to perform accurate diagnosis coding!
@ou should al'ays code to the highest le#el of
specificity! If possi%le, e.tend the code to the fourth or
fifth digit! Ae can ta$e the pre#ious e.ample of
dia%etes mellitus to e.plain this!
2!" &ia%etes mellitus
2!#2" &ia%etes 'ith hyperosmolarity
2!#2!" &ia%etes 'ith hyperosmolarity, type
II or unspecified type, not stated as
uncontrolled
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+ere the three digit code 62;04 represents diagnostic
category 'hile the four digit code 62;0!24 represents
associated complications and fi#e digit code 62;2!204
represents the type of dia%etes and its le#el of control!
&epending upon the dia%etic condition, you may need
to use the entire fi#e digits to specify it accurately!
If there is more than one diagnosis listed for your
patient, prioritie them! @ou should first code the
primary diagnosis (the ma0or reason for the patient,
follo'ed %y the ne.t most diagnosis and so on!
If you suspect a specific condition for your patient,
code only the sign or symptom that %rought that
patient for the particular #isit until you confirm the
diagnosis 'ith further tests! Other'ise ma$e a
definiti#e diagnosis!
8in$ the I)&-9 codes reported to the rele#ant ser#ice
code on the claim form! "his 'ill help payers to
identify 'hy such a ser#ice 'as rendered and esta%lish
medical necessity!
*hysicians are responsi%le for choosing the codes and
su%mitting them to the payers! In the case of large medical
practice groups, it may not %e that smooth for physicians to
%alance their time %et'een patient care and clinical
documentation! /edical practices can team 'ith coding
professionals to sol#e this issue and su%mit accurate claims
'ithin deadline to o%tain correct reim%ursement!