When you should use additional diagnosis codes on a claim

During our recent Code & Chat session, our experts answered this question: When should you use additional diagnosis codes on a claim to support P3-P5 physical status modifiers? Quarterly Code & Chat sessions answer your burning questions about anesthesia coding.

As a coder, you can include up to 12 diagnosis (DX) codes on a single claim.  Additionally, some payors may restrict the allowable diagnosis pointers per line item to no more than four. 

The submitted medical record must support the use of the selected ICD-10-CM code(s), and all diagnoses relevant to the patient encounter should be reported on the claim. Driven initially by HCC reimbursements, coding audits by payors have prompted recoupments citing medical necessity or other diagnosis deficiencies related to diagnosis coding even when HCC revenue is not a factor.  

Many payors are citing claims with the assignment of diagnoses that do not fulfill the M.E.A.T. acronym. To assign an ICD-10 code for a condition it should be relevant to the current encounter as evidenced by the provider’s documentation of one of the following clinical considerations related to the condition:

M = Monitor

E = Evaluate

A = Assess

T = Treat

In short, a list of conditions copied from a problem list or similar, would not support ICD-10 code assignment. 

The primary diagnosis is generally identified as the reason for the encounter. The secondary or subsequent supporting diagnosis/es will be reported as relevant to the documentation stating the reason for the physical status (P3-P5), support for the medical necessity of monitored anesthesia care (MAC) and/or support of an anesthesia service when “anesthesia care is not typically required.” 

The American Society of Anesthesiologists (ASA) publishes an ASA Physical Classification System that is available for review in the annual Relative Value Guide®.  An online version is also available.  This tool is described by the ASA as guidance for communicating factors that may contribute to perioperative risks.  While it is also stated that the physical status classification level is a clinical decision, the table offers examples that coders may consider when assigning ICD-10 codes to support a physical status.  

Lastly, carriers may have individual guidelines within a Local Coverage Policy. Review your individual payors for any specific coding requirements when coding and submitting a claim.

As always, the HANK/ACE team is here to help. Contact us with your questions about when you should use additional diagnosis codes on a claim.