How Does Medicare Know What’s Wrong With You?

A patient’s clinical conditions are communicated to their insurance carrier through a unique alphanumeric code language on an electronic claim form.  For example, a common diagnosis like hypertension is not stated on the claim as such, it is represented with the code 401.9, essential hypertension; unspecified.  If one has had coronary artery bypass surgery in the past the physician will indicate that by using the diagnosis V45.81, other postsurgical states; other postprocedural status; aortocoronary bypass status.  This set of alphanumeric codes is called ICD-9 CM which is the International Classification of Diseases, 9th Revision Clinical Modification.

Below is a copy of a statement for a patient visit.  In this instance, the physician has indicated that the patient is coming in for a routine general medical evaluation (V70.0) and they have palpitations (785.1) with an unspecified vitamin D deficiency (268.9) and pure hypercholesterolemia (272.0).

 

With codes ranging from 001 to 999 plus the E and V status codes there are 13,600 illnesses and conditions represented in this code set.  The correct reporting of these codes become critical as they paint a picture to ones insurance carrier, in particular Medicare and the various Medicare Health Maintenance Organizations (HMO).  These diagnoses determine whether a service provided (which is represented by a completely different set of alpha numeric codes) is deemed medically necessary.  In essence one truly is merely a set of numbers as far as insurance is concerned.

 ICD and its numerous modifications is maintained by the WHO (http://www.who.int/classifications/icd/en/) and is used worldwide.  ICD had its beginning in 1850s originally being called the International List of Causes of Death and was utilized by the International Statistical Institute.  In 1948 the WHO stepped in and ICD has been under their purview ever since.  Many revisions have occurred through the years and in October, 2013 the latest version, ICD-10 CM will be in force.  This revision contains the most sweeping changes ICD has seen to date.

 As we discussed in prior posts, healthcare is a living, changing, entity.  At one time physicians, nurses and other technicians dominated the healthcare workforce.  Today, it is much more diverse.  With a code set of over 13,000 diagnoses one can see it would be cumbersome for a physician to thoroughly understand how to use it.  Without a properly assigned diagnosis there may not be reimbursement for a service rendered.

Now integral to the revenue cycle of healthcare are professionals who translate simple English into these codes.  Professional organizations have emerged to train, certify and ensure these individuals maintain a high standard of ethics.  As mentioned earlier these diagnosis codes directly correlate to payment for services. These professionals work with the clinicians to ensure that the diagnosis reported are clearly supported in the medical record; thus ensuring compliant reporting and protecting the provider from risk.

 

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