BPR Audit Notes

DIAGNOSIS CODE REVIEW

A medical specialty claims audit should incorporate an early analysis of provider diagnosis code use. Medical providers are required by CMS to supply a specific and accurate diagnosis code when submitting Medicare claims, and are expected to follow the same rule for Medicaid and other commercial insurance claims. Failure to include an accurate and specific diagnosis code that justifies the claim procedure code prevents effective review for medical necessity. Such a claim should be returned to the provider for proper coding, or should not be paid. ICD-9-CM coding that describes symptoms can be acceptable, but only if this is the highest level of certainty documented by the physician. Codes describing symptoms, like the more specific diagnosis codes, must also justify the related procedure code choice.

BPR has developed a comprehensive method for evaluating medical specialty diagnosis code use which enables medical insurers to proceed confidently over this potential obstruction to a useful audit.