Details! Details! Details!

There are many nuances involved in correct coding. They all come back to the details. When details are lacking it opens the door to incorrect billing, and payment delays. Details are important for both procedure and diagnosis coding. The lack of detail can result in "up" coding or "down" coding. The first can result in allegations of fraud and abuse; the second can result in loss of earned income.

Lack of diagnosis and/or procedure details can result in claim denials and payment delays. As a reminder, ICD10 is looming on the horizon with a proposed implementation date of October 2013. Instead of approximately 10,000 possible diagnosis codes, we will go to 68,000 possible codes. The Centers for Medicare and Medicaid Services (CMS) have announced an Implementation delay; they just have not yet told the provider community the length of the delay. ICD-9 has been in use since 1979 and no longer fits terminologies and classifications used in the 21st century. The current system's available numbers have been exhausted and the growing need for quality data cannot be accommodated within that system. ICD10 requires much more specificity and is an alpha-numeric system.

We will cover some examples to illustrate the importance of providing as many details as possible for correct coding and reimbursement purposes.


  • Did you know that in ICD9-CM, a "wound" is considered an injury? Therefore when an injury diagnosis is used to bill the claim, the carrier will delay payment until they investigate, determine how the injury occurred and/or if another insurance is obligated to pay the claim. If it was an auto accident the automobile insurance carrier might be responsible for reimbursement. If the injury occurred at work then workers compensation coverage would apply. Did they fall in a store? Maybe the store's liability insurance will pay. This delays your payment.
  • When you state the diagnosis as a wound and it is not an injury, it could result in a delay lasting 6 weeks to several months while the carrier suspends the claim and develops diagnosis information and/or "injury" details. They send questionnaires to the patient and their physicians to complete. These requests for additional information delay payment until all of the questionnaires are returned and reviewed. This delay would be totally unnecessary if the "wound" is identified at the time of submission as an ulcer, a post operative infection, a non-healing surgical wound, an infection such as cellulitis or osteomyelitis, or any other type of non-injury wound.
  • If detailed diagnosis information is provided by the physician from the start, the claim can be coded correctly and carrier reimbursement received within 30 days.
  • Another example of the importance of correct diagnosis coding is post operative complications. Any complication resulting from a procedure has a special diagnosis which must be used to indicate this. It is not a wound.
  • Hematomas can be post-operative complications, a result of trauma (injuries, fractures, contusions), or be spontaneous such as from intracranial non-traumatic bleeding.
  • When hardware is infected or broken there are diagnosis codes to indicate this. There are diagnosis codes to indicate post-operative complications affecting nervous system, cardiac complications, gastro-intestinal, respiratory, and urinary complications, accidental laceration during a procedure or foreign body accidentally left during a procedure and many others. Each of these requires a separate and distinct diagnosis code.
  • Unless billed correctly with a post-operative complication code, the carrier will of course assume the submitted code is a new condition and may delay claim payment while they develop details about this "injury" condition.
  • Required pre-authorization issues may come into play, and/or questions of fraudulent billing can arise when intra or post-operative complications such as foreign body accidentally left, operation on wrong body part, or hospital acquired central line infections are not correctly reported. These last complications are specially tracked by both the carriers and government entities and special reimbursement or rather non-reimbursement rules may apply.


Incorrect reporting of procedure services also directly affects your income. Some procedures can be accomplished utilizing various approaches and the approach determines the correct procedure code and units to bill. Examples:

  • Pinning for proximal femur fractures. Percutaneous pinning carries anesthesia base units of 4, while open pinning carries base units of 6.
  • Inguinal hernias can be repaired open (4 base), or via laparoscopy (6 base).
  • Lumpectomy is 3 base units, lumpectomy with lymph node dissection or biopsy is 5 base units.
  • Simple orchiectomy is 3 base units, radical inguinal approach is 4 base units, and radical abdominal approach is 6 base units.
  • Base units differ for diagnostic arthroscopies versus therapeutic arthroscopies.
  • Thoracoscopy units differ depending on whether diagnostic or therapeutic and whether one lung ventilation is utilized and properly documented.
  • Multiple level spinal procedures and those utilizing instrumentation carry higher units. In many cases cervical and thoracic levels allow higher units than lumbar levels, and anterior thoracic cases utilizing one lung anesthesia allow even higher base units.

Did you know?

There are up to 21 different ASA codes from which we can choose to bill for a wound depending on the site of the wound. The problem that the coder has to consider is

  1. is it on the arm? If yes, Upper? Lower? Hand?
  2. Is it on the leg? If yes, is it Upper? Lower? Toe?
  3. Is it on the head?
  4. Is it on the abdomen?
  5. Is it on the back?
  1. Is it skin only? Or
  2. Does it go to Muscle? Or
  3. Is the bone involved?
  4. In addition, where is the wound?
  5. Is it post op?
  1. Is it a current injury?
  2. Is it nonhealing from a prior surgery?
  3. Is it a non-healing ulcer?
  4. Is it a chronic versus acute injury?
  5. Is it secondary to diabetes?

Q and A


I received a claim to code today that states "Abscess" as the Diagnosis and "I&D of the abscess" as the procedure. How do I code this claim for payment?


I would need to be provided additional detail. It would appear that the anesthesiologist did not provide enough information to bill this claim as is. Although there is a generic diagnosis code for the abscess, specific detail as to the location of the abscess is needed in order to bill the procedure correctly. For example, an abscess removed from the neck would provide a base value of 5 ASA units whereas an abscess removed from the chest region would be reimbursed at 3 ASA units. As you can see from this example, money could be left on the table by not providing as much detail about the procedure as possible. Therefore, this record will have to be returned to the physician for clarification.