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Choose correct ICD-9-CM codes to effectively screen for medical necessity

HIM Connection, November 2, 2004

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A complete and accurate understanding of the coding guidelines for diagnostic tests is critical to the medical-necessity process. Ensure your facility bills Medicare for medically necessary services only by following these rules for reporting ICD-9-CM codes:

• Use the ICD-9-CM code that describes the patient's diagnosis, symptom, complaint, condition, or problem. Do not code a suspected diagnosis.
• Use the ICD-9-CM code that is chiefly responsible for the item or service provided.
• Assign codes to the highest level of specificity. Use fourth and fifth digits where applicable.
• Code chronic conditions when they apply.
• Code all documented conditions at the time of the visit that require or affect treatment.
• Do not code conditions that no longer exist.

Medicare bases its medical-necessity determination on the primary ICD-9-CM code assigned for a test or service. Use the following guidelines when assigning the primary diagnosis code:

• Confirmed diagnosis--Code the diagnosis confirmed by the diagnostic tests. You can also report the signs or symptoms that prompted you to order the test as additional diagnoses if they are not explained by or related to the confirmed diagnosis.
• Normal findings--If the diagnostic test did not provide a diagnosis or was normal, code the signs or symptoms that prompted the study.
• Uncertain findings--If the results of the diagnostic test are normal or nondiagnostic and/or the referring physician records a diagnosis proceeded by words that indicate uncertainty (e.g., probable, suspected, questionable, rule out), the interpreting physician should not code that diagnosis. The interpreting physician should instead report the signs or symptoms that prompted the study.
• Screening (no signs or symptoms given)--Facilities use physician documentation to determine whether a test is considered a screening or diagnostic. They perform screening tests without any signs or symptoms of the disease. For tests ordered without signs or symptoms, report the screening code as the primary diagnosis code. Report any condition discovered during the screening as a secondary diagnosis.
• Incidental findings--Never list incidental findings as the primary diagnosis. However, you may report incidental findings as secondary diagnoses.
• Unrelated or coexisting conditions--The interpreting physician may report unrelated and coexisting conditions or diagnoses as additional diagnoses.

Proper ICD-9-CM code assignment must be based solely on documentation, not on the arbitrary assignment of an ICD-9 code that will be reimbursed by the insurance company. Code the ICD-9-CM code to the highest degree of accuracy and completeness based on the results of the test, or use the signs/symptoms that prompted you to order the test.

Billing for nonmedically necessary services
If a patient receives items or services that are not medically necessary, the facility must still submit a claim to Medicare. Otherwise, your facility is in violation of Medicare's mandatory claims submission provision and could face sanctions. When submitting a claim to Medicare for a noncovered service or a service that is not medically necessary, use the appropriate condition codes/modifiers to designate services as such.

Note: For exclusions and technical denials, providers only need to submit a claim if the patient requests it.

This excerpt is adapted from the Medical Necessity Training Handbook for Nurses and Hospital Staff.

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