Q & A of the day: Submitting ICD-9-CM codes – from claims only?
Q: Does a health plan need the facility’s (clinic) permission to add a chronic condition to a claim when the evidence of evaluation and treatment is found in the documentation? Our problem is the very rural areas are coders who do not know anything about risk adjustment and are constantly disagreeing with out findings because they think you ONLY code the reason for the visit no matter what information I give them regarding the importance of coding chronic conditions when addressed/assessed and treated. Any guidance you can offer would be a great help!
A: A health plan does not need a provider’s permission to submit documented ICD-9-CM codes to the RAPS database. Any documented chronic or acute condition that a certified coder could abstract from the proper face-to-face documentation (i.e. signed, dated, credentialed by acceptable specialty type) may be submitted for risk adjustment purposes. All of the chart auditing vendors and any coders working for a plan may abstract and code diagnoses that are properly documented and submit to the plan or submit to CMS on behalf of the plan.
Ideally, these additional codes would be submitted on claims in the first place for ease of processing, but you may submit ICD-9-CM codes to RAPS that have been collected in other means, such as a superbill, chart audit, etc.
2 Comments
Other Links to this Post
RSS feed for comments on this post. TrackBack URI
Leave a comment
You must be logged in to post a comment.
By Lmarie, May 16, 2011 @ 9:30 AM
Thank you for your quick response! Do you know where I might find this in either the Risk Adjustment training manual or on the CMS website?
By J. Matt Yuill, M.D., CPC, May 16, 2011 @ 9:46 AM
See pg. 2-2, and 7-3 of the risk training guide.