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Acupuncture Today
February, 2006, Vol. 07, Issue 02
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Denials Due to Truncated or Incomplete Diagnosis

By Samuel A. Collins

Q: I am getting denials stating my diagnosis is truncated or incomplete. What does this mean?

A: Realize the majority (if not all) of these denials are not because there are new codes, but that codes billed are being scrutinized more carefully for accuracy.

The ICD9-CM (International Classification of Diseases, 9th Revision - Clinical Modification) contains all the diagnoses currently billable under all insurance claims. These codes contain three, four or five digits. For the diagnosis to be complete and accepted, it must contain all of the necessary digits. Due to the implementation of HIPAA, insurers are relying more on electronic examination of billing and are required to reject claims not containing accurate codes. Consequently, if the diagnosis is incomplete it's rejected. You must verify all of your current diagnoses, particularly if you diagnose using a list, where the list has not been verified by the doctor or staff that it's complete to the highest level.

An example of the coding variety of digits would be the common cold (nasopharyngitis), which is coded 460 (a three-digit only code) with no additional digits needed to be complete. Cervical spine strain/sprain is 847.0 (a four-digit only code) with no additional digits needed to be complete. Wrist strain/sprain requires five digits to be complete, and is coded 842.00 (wrist sprain/strain, unspecified site), 842.01 (wrist strain/sprain, carpal joint), 842.02 (wrist strain/sprain, radiocarpal joint) or 842.09 (wrist strain/sprain, other) - meaning you can identify the region, but it is not listed above, such as radioulnar joint - distal.

Prior to HIPAA implementation, an incomplete diagnosis code may have been routinely accepted as the reviewer could/may ultimately ascertain what the code was for and accept it. For instance, in the past, many offices would bill migraine headaches as 346.0. Even though it requires a fifth digit to be complete, it would be accepted and claim-processed. Now if 346.0 is billed, the claim is rejected for incorrect and/or invalid diagnosis. Many offices are at a loss, as they had billed the code in the past and were never aware it was incorrect, but now, when it is not accepted, they do not know what to do. (By the way, 346.00 is for a classical migraine without mention of intractable pain, while 346.01 is a classical migraine with mention of intractable pain.)

Therefore, if your office is not coding from a diagnosis code book and only using a "cheat sheet" for diagnosis, it is imperative that the sheet be verified, and that all of the codes on the sheet are correct for the number of digits and the level of specificity. For instance, shoulder strain/sprain, though only a four-digit code, has 10 possibilities (840.0 to 840.9, depending on the specific shoulder structure). Disc displacement of the cervical spine is coded 722.0 (a four-digit code), while 722.10 is used for the lumbar spine and 722.11 for the thoracic spine (both five-digit codes). It is recommended to have a complete and current (published yearly) codebook of ICD-9 codes for reference. There is an edition of the book that not only contains the diagnosis codes and descriptions, but also definitions of many codes. This version is referred to as the professional edition or the "complete" version (volumes 1 and 2). There also is a free Web site where an ICD-9 code can be checked for specificity and use ( I recommend you have a complete book, as once the doctor has a chance to look at all the varied possibilities of ICD-9 codes, often they are able to find codes that have a more accurate description of the patient's condition and might lead to increased levels of allowed care.

Click here for more information about Samuel A. Collins.


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