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Terms in this set (99)
format and typeface, eponyms, abbreviations, punctuation, tables, includes notes, excludes notes, inclusion terms, other, other specified, and unspecified codes, etiology and manifestation rules, and, due to, with, cross references, including, see, see also, see category, and see condition
• Codes on claim forms should tell the story about the patient's care and the need for services.
• The diagnosis codes explain why the patient needs healthcare services and the CPT/HCPCS procedure codes describe the services that are performed.
• The relationship between diagnosis and procedure codes is described as meeting medical necessity.
• Coding professionals must be sure that any association of ICD-10-CM diagnostic codes with CPT/HCPCS procedure codes is logical and appropriate.
• Linking the appropriate ICD-10-CM diagnosis to the correct CPT code supports medical necessity.
• Medical necessity answers the following question for those paying the claim:
• Was the service provided logical for the diagnosis reported?
• Example: Patient's chief complaint is lower leg pain.
• The physician orders a lower leg x-ray and an electrocardiogram (EKG).
• The lower leg pain is linked with the x-ray, but there is no logical symptom or diagnosis to link with the EKG.
• Review of the health record may reveal an existing condition, such as premature ventricular contractions, or a symptom, such as tachycardia.
• Documentation must support the procedure or service provided; otherwise, the claim will be denied.
• Medicare and many commercial third-party payers establish coverage limits for certain services.
• Reimbursement claims for services with coverage limits (for example, inpatient psychiatric care) must include sufficient diagnostic information to support the medical necessity of the services provided.
• This diagnostic information is communicated in the form of ICD-10-CM codes.
• Medicare policies include two types of coverage limits: national coverage decisions (NCDs) and local coverage determinations (LCDs).
• These policies include decisions on items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury.
• For example, a Medicare policy may deny coverage for cosmetic surgical procedures.
• CMS establishes contractual arrangements with Medicare Administrative Contractors (MACs) who process Medicare claims in local geographic regions.
• These contractors are responsible for making coverage decisions for Medicare beneficiaries, and the contractors base their decisions on established national coverage requirements for specific medical supplies and services.
• For cases that are not covered by existing national policies, contractors may make LCDs at their own discretion.
• A list of the Medicare coverage policies can be found on the CMS website.
• The following policy is an example of an LCD:
• Example: CPT code 43235, Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure), is covered by Medicare only with an appropriate ICD-10-CM diagnosis code submitted on the claim, such as (abbreviated list for illustration):
• B37.81 Candidal esophagitis
• C15.3 Malignant neoplasm of upper third of esophagus
• C16.4 Malignant neoplasm of pylorus