What are “THE BEST” diagnosis codes?

Dec 1, 2023 | Consultants

by Marty Kotlar, DC, CPCO, CBCS • 

President of Target Coding • 

Question: Dr. Kotlar, I’ve heard that insurance companies will pay for 30 visits if I submit a long-term treatment diagnosis such as a herniated disc. Is this true?

Answer:  The answer is yes, no, maybe. To begin with, choose diagnosis codes that accurately depict the presenting complaint and underlying condition regardless of the patient’s insurance plan or financial situation.  Each patient’s condition and response to treatment must have a chiropractic necessity to warrant the number of services reported for reimbursement. Insurance carriers do not expect that all patients will routinely require the maximum allowable number of services offered under the benefit plan. Additionally, insurance companies, malpractice carriers and state boards require the medical necessity for each service to be clearly demonstrated in the patient’s chiropractic record. It’s not enough to pick a diagnosis just because it “feels” right. In order for your services to be considered reasonable and justifiable, health plans, state scope of practice laws and standard practice acts require that your diagnoses have validity, are compatible with your procedure codes and are substantiated in your documentation.  The clinical rationale for choosing a diagnosis must be in writing, be part of your plan of care and entered in the patient chart notes. The diagnosis codes you choose must be extremely accurate. If a patient presents to your office with low back pain, leg pain and leg numbness, do not automatically assume and report a herniated disc. A diagnostic test would be appropriate in this case to rule out or rule in disc pathology.

Documentation supporting chiropractic care, whether it’s for maintenance/wellness care or medically necessary care, should be legible, reasonable, maintained in the patient record and be available upon request. All procedures must be furnished according to a plan of care determined by the provider.  Document the appropriate history, examination, diagnosis, functional assessment, type of treatment, the body areas to be treated, date therapy was initiated, and expected frequency and number of treatments. Documentation should indicate the prognosis for potential restoration of function in a reasonable and generally predictable period of time for especially for insurance reimbursable care. The treatment plan should be updated any time there is a change in condition (e.g., acute exacerbation or new condition) or if the patient significantly improves or worsens.

Measure functional changes after every re-examination and record them in such a way as to clearly document the patient’s actual progress (or lack thereof). The expected recovery period as it relates to your written treatment plan and reported diagnoses should be documented in the chart notes along with the progress being made and anticipated duration of further treatment.  There should be an indication as to if or why the patient still requires treatment. This suggestion may not apply to your patients receiving chiropractic maintenance/wellness care.  Any changes in the diagnoses must be noted in the chart notes. Review your ICD-10 coding policies and procedures with your designated compliance officer and all billing staff members.

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established or confirmed by the provider. While specific diagnosis codes should be reported when they are supported by the available documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. It would be inappropriate to select a specific code that is not supported by the documentation or conduct medically unnecessary testing in order to determine a more specific code. The CMS definition of medical necessity includes the treatment of a patient’s condition must be consistent with the diagnosis and be reasonable and necessary for the diagnosis and to improve function. Here again, insurance companies, malpractice carriers and state boards require the necessity for each service and diagnosis to be clearly demonstrated in the patient’s record. Insurance companies are very good at analyzing claims to see if the diagnosis and procedure codes are reasonable, necessary and supported by appropriate documentation.

The above information is for educational purposes, is not intended to be a substitute for your clinical decision-making and should not be construed as written policy for any organization or federal agency. I cannot guarantee that this information will guarantee payment from any health plan or patient.

Email info@targetcoding.com to receive a FREE ICD-10 “cheat sheet.”

Dr. Marty Kotlar is the President of Target Coding. Over the last 12 years, he has helped hundreds of chiropractors, physical therapists and acupuncturists with compliance as it relates to billing, coding, documentation, Medicare & HIPAA. Dr. Kotlar is certified in compliance, a certified coding specialist, a contributing author to many coding and compliance journals and a guest speaker at many state association conventions. He can be reached at 1-800-270-7044, website – www.TargetCoding.com, email – drkotlar@targetcoding.com.