Coding: Your Top Coding Concerns Solved
Billers’ Old Wives’ Tales; Unlisted Codes: Is There Any Point?
By Bill Dacey Let’s look at some of the more common and pervasive myths that surround coding and billing for professional services.
Coding correctly results in payment. This can be true. But coding a service correctly is only part of the equation. It is true when the service provided is a covered service, all demographic and coverage issues are properly aligned, deductibles have been met, and there are no relevant issues that trigger a denial. There are a lot of boxes on that CMS-1500 form.
The more diagnosis codes I put on a claim form, the more money I’ll get. False. With some exceptions, there is no direct relationship between the amount of money you are paid for CPT codes and either the number or severity of the diagnosis codes you assign to them. CPT codes describe what the provider did; ICD-9 codes explain why. A single ICD-9 code is sufficient for higher-level E&M services or for complex surgeries. Additional ICD-9 codes aren’t necessary unless the ICD-9 official guidelines state that you need them.
Payers may down-code some CPT payments based on procedure-to-diagnosis-code edits, but that’s just a first-pass edit. If you appeal the claim and your original diagnosis and the circumstances warrant the procedure, you will likely get paid. Some diagnosis code ranges, such as those in mental health, can trigger payment reductions on the CPT side by individual payers. This is a matter of policy — policies you need to learn.
