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Auditing Your Diagnosis Codes

Dr. Karen Sedore
in Coding

Auditing Your Diagnosis Codes

It’s hard to believe that ICD-10 has been in use now for over 4 years. It seemed like an impossible task to convert all of the ICD-9 codes and to learn what all of the alpha-numeric characters meant. Although the biggest change came in 2015, updates have been happening yearly and some payers have also made modifications to their policies based on diagnosis coding. Offices that are still relying on cheat sheets that converted the old codes to the new ones may find more claims being denied because those codes no longer exist or have become more specific. Now is a great time to take a look at the diagnosis codes you are currently using to ensure they are a proper fit for patients’ conditions.

Auditing Your Diagnosis Codes

When it comes to audits, it is always better to be proactive rather than reactive. Anything that can be done in the office to improve the quality of your work can help increase accuracy, efficiency, and sometimes even profits. Two major types of internal audits can be performed: analysis of all of the diagnosis codes used in the practice and random chart audits.

Looking at the Big Picture

Chiropractic care is so patient-centered that it can be hard to remember to take a step back and get the 15,000-foot overview of the practice as a whole. Electronic billing systems have made this process much simpler with the wide variety of office statistics that can be analyzed. Start by printing a list of all of the diagnosis codes that have been used in the office within the past year and check the following for accuracy:

  • How often are pain codes used? Myalgia, cervicalgia, dorsalgia, lumbago, and other pain codes are very generic considering that many patients present with pain as their major reason for seeking treatment. It is quite likely that a thorough history and examination process would identify a more specific diagnosis. It would be more appropriate to list that diagnosis on the patient’s claim form. A claim that contains a pain code along with a neurologic complaint such as radiculopathy or sciatica is likely to be denied since ICD-10 guidelines state the two codes should not be billed at the same time. This is noted as “Excludes 1” in your ICD-10 guidebook.
  • Has the code been updated or deleted? Some codes have been updated to not only include the spinal region but now include the specific level. Older codes will no longer be valid and will result in claims being denied.
  • Are you using the correct 7th digit? The 7th digit of the ICD-10 code specifies the encounter type. Not all codes require this.
    • A- This character signifies that this is the initial encounter. It is used the entire time the patient receives active care for that condition.
    • D- This is used for subsequent encounters where the patient is receiving routine care for a condition during their recovery phase of treatment.
    • S- This is used for sequela-the complications or conditions that are a direct result of a condition but are considered a “late effect.”
  • Are any codes “not otherwise specified”? Diagnosis coding should be as specific as possible. If codes allow you to indicate the body area or laterality of the condition, do so.

Knowing the diagnosis codes used in the office can benefit more than just billing reimbursement. By evaluating how often a code is used, the office may be able to target marketing to commonly treated conditions. It may be possible to determine the potential return on investment for an expensive piece of equipment based on the number of patients who would benefit from its use.

Case by Case Basis

Another way to audit diagnosis codes is to review each chart individually and analyze coding accuracy. In other fields of healthcare, the patient’s documentation is completed before codes are chosen and these are typically selected by a certified coder, not the doctor as is often the case in chiropractic. Without a second set of eyes reviewing the notes for the necessary details, it is very easy to miscode patient claims. When the diagnosis coding is incorrect, the billing may be wrong as well. The chart auditing process may be done prospectively before submission or retrospectively after the claims have already been submitted. Prospective auditing must be done rather quickly to ensure that claims can be submitted appropriately, timewise. However, the positive side of this type of audit is that claims can be corrected, if necessary, before they ever leave the office. Retrospective audits may require claims to be resubmitted if significant errors are found.

All of the same issues that can be addressed with a full-blown coding analysis may also be reviewed in a chart audit. The main advantage of this type of audit is that it allows a deeper dive into the documentation to ensure that the diagnosis can be supported. The amount of care that is considered medically necessary is directly tied to the diagnosis and is another reason why the coding should be as specific as possible. For example, a diagnosis of cervicalgia may only warrant a few visits whereas a more severe condition such as cervical stenosis or a disc herniation would take longer to treat. Doctors may only diagnose to the highest level of specificity that can be proven. Coding signs and symptoms may be appropriate if waiting for tests or imaging that will be used to confirm a potential diagnosis, but these should be updated as soon as possible. The diagnoses that are used can also be evaluated to see if they support the rationale of the treatment that was performed.

It is important to stay current with changes involving diagnosis codes. Audits of this type allow for an internal review and analysis of the practice that can extend outside of just the scope of billing to help increase profits. By investing in training and coding resources for your staff, you show your commitment to accuracy and compliance as well.

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Dr. Karen Sedore has over 10 years of experience working in the chiropractic profession. She began as a manager specializing in billing and medical necessity as well as taking on chiropractic assistant responsibilities so that she could be more involved with patient care. She also has experience with income tax preparation and has helped hundreds of families and small businesses with tax planning. In 2016, Dr. Sedore received her doctorate in Chiropractic from National University of Health Sciences. She joined KMC University in 2017 and assists doctors and their staff in her current role as an Membership Advisor.