Suche
Mein Konto
Coding at the highest level of specificity
Insurance carriers often dispute claims that they were not coded with the highest level of specificity. Because many billers are not programmers, they often don't understand what went wrong or how to fix it. When a service line is declined for this reason, they say the diagnostic code needs to be more specific. Some diagnostic codes are only three or four digits long, but many are five digits long. The diagnosis must be coded at the absolute highest level for this code, i.e. h. with the highest number of digits for the code used. For example, the diagnosis of high blood pressure starts with 401. However, if you submit an application with a diagnosis of 401,...
Coding at the highest level of specificity
Insurance carriers often dispute claims that they were not coded with the highest level of specificity. Because many billers are not programmers, they often don't understand what went wrong or how to fix it.
When a service line is declined for this reason, they say the diagnostic code needs to be more specific. Some diagnostic codes are only three or four digits long, but many are five digits long. The diagnosis must be coded at the absolute highest level for this code, i.e. h. with the highest number of digits for the code used.
For example, the diagnosis of high blood pressure starts with 401. However, if you submit an application with a diagnosis of 401, it will be rejected. The code 401 requires a 4th digit. 401.0 is malignant essential hypertension. 401.1 is benign essential hypertension. 401.9 is unspecified essential hypertension. So, to settle a claim with a diagnosis of high blood pressure, it must be in either 401.0, 401.1, or 401.9.
Another example of a diagnosis that needs to be settled with greater specificity would be diabetes. 250.0 indicates diabetes, but you need a 5th digit to indicate what type of diabetes it is. 250.00 is diabetes mellitus type 2, 250.01 is diabetes mellitus type 1 (juvenile type) and 250.02 is diabetes mellitus type 1 uncontrolled and so on.
As you can see in the example above, simply typing 250.0 doesn't indicate exactly what the problem is. Without the fifth digit, the application lacks enough information to be processed and will therefore be rejected.
If you are unsure whether the diagnosis is coded with the highest specificity, you can look it up in an ICD9 codebook or on the Internet. There are several websites with current ICD9 codes. They indicate whether the code is encoded at the highest level.
Some practice management systems have scrubbers that catch coded diagnoses and alert you. Sometimes the biller will recognize a truncated diagnosis (or a diagnosis that requires an additional digit).
In either case, the biller should return to the coder or provider and ask them to specify the diagnosis code in more detail so that the claim can be resubmitted.
Copyright 2009 – Michele Redmond
Inspired by Michele Redmond