claims and icd coding

[doctoramin]

I would like to know how exactly icd 9 or 10 coding are related to denying or in processing of health claims?
How does undercoding or higher coding influence the claim processing?

[Amir Mostafaie]

Dear doctoramin,
Medical offices lose thousands of dollars on coding errors every year. Some estimate that  in any sample of 200 claims it is not uncommon to find 80 percent with the wrong code altogether, 41 percent over-coded, 45 percent undercoded and 17 percent billed for services not documented in the record.

Both undercoding and overcoding are undesirable, and should be avoided. Most of the codes we see in the United States today are version 9, called ICD-9-CM codes. ICD-9 codes describe the reason for the medical services to commercial and government payers in alpha/numeric codes. Not linking the diagnosis to the proper code can lead to a denied claim.  The diagnosis or clinical suspicion must be present for the procedures to be considered medically necessary.

With few exceptions, the paperwork we receive when we leave a doctors’ office will contain both CPT codes (Current Procedural Terminology) to describe the service that was rendered for billing purposes, and ICD-9-CM codes to describe why that service was provided.

The most current list of codes in use is ICD-10. This list was first used in the United States in 2007. Minor revisions added to ICD-10 codes were made available in early 2009 by the NCHS. Globally, most other countries in the world have implemented the ICD-10 codes. There are some major differences between the two code sets, the transition is very expensive, and in my knowledge most American providers have not yet upgraded to the ICD-10 system.

Sincerely,

Amir Mostafaie