More than ever, myriad payment pitfalls threaten a pain coder's every step. Make sure you know how to navigate pain code compliance traps and find every hidden penny along the way. Go through this real life scenario on pain ICD-9 medical coding provided by our expert in a medical coding conference and bring new clarity to your worst pain diagnosis coding challenges.
Suppose your pain doctor doesn’t really document an assessment or diagnosis list. His dictation is more of a combined paragraph. How should you find what ICD codes to be put for his services?
Some of the providers dictate in a narrative file almost like their conservational method. And they don’t have separated out. And it's more difficult for billers and coders to locate it.
Coding and Compliance Tip: For accurate reporting, this is maybe a learning moment that you go back to your provider and have a communication process so that he understands the important of clearly reporting or carving out or some method of identifying to you as a biller as to the reason for the encounter, the reason for the services.
And you may just establish a communication process that works for you. But it's very important that it's clearly reported for accurate medical coding and billing. Remember payers use this as the basis for medical necessities. So if they're reviewing services in a RAC audit or say for instance have payer audit and they don’t see clear documentation for that diagnosis code that was reported, providers can have great problems with that.
Our expert stated this in the medical coding conference that more of a process of communication between you and your provider so that you clearly understand whether they change habits to using a list or they underline certain conditions. It's what you work out between the two of you. But what's important is that the reason for that service is accurately reported.
Visit our ICD-10 medical coding conference page for more on medical coding rules and guidelines.