Diagnosis codes convey the reason for the visit, and they also capture risk—something that many payers increasingly consider when calculating reimbursement. It’s important for physicians to ensure that the information they document is as specific and complete as possible, said Terri Thomas, RHIA, clinical documentation specialist in San Leandro, Calif., who spoke during AAPC’s HEALTHCON, April 8-11 in Orlando, Fla.
HEALTHCON offers educational sessions and networking opportunities for medical coders, billers, payer representatives, practice managers, attorneys, physicians, and other healthcare business professionals.
Accurate and complete documentation ultimately reduces denials, said Thomas. Translation? Physicians retain the revenue they generate.
Unspecified diagnosis codes often wreak havoc on cashflow because many payers simply deny them, said Thomas. “We need to be as specific and compliant as possible. That’s one of the reasons why we moved to ICD-10,” she said.
Thomas discussed these seven diagnoses and provided checklists of what physicians should document to avoid denials:
• Any association with chemotherapy, neoplasms, drugs, chronic kidney disease, end-stage renal disease, or other chronic disease, when applicable
• Due to bleeding (including the site), when applicable
• Specificity (i.e., acute, chronic, or acute on chronic)
•Type (e.g., deficiency, aplastic, pernicious, or postoperative)
• Any related tobacco use, dependence, or exposure
• Any chronic signs and symptoms
• Medication noncompliance, when applicable
• Presence of chronic obstructive pulmonary disease or bronchitis, when applicable
• Severity (i.e., mild intermittent, mild persistent, moderate persistent, or severe persistent)
• Triggers or environmental risk factors
• With or without acute exacerbation
• Type (i.e., acute or chronic)
• Infectious agent (i.e., viral, bacterial, or obstructive)
• Associated conditions/contributing factors (e.g., influenza, pneumonia, or emphysema), when applicable
• Tobacco use, abuse, dependence, or exposure, when applicable
4. Chronic obstructive pulmonary disease
• Body mass index
• Smoking status, including history of smoking, when applicable
• Use of home oxygen, BIPAP, or CPAP, when applicable
• With acute exacerbation, hypoxemia, bronchitis, asthma, emphysema, or upper respiratory infection, when applicable