Recently I was at a community meeting and a representative from the local Accountable Care Organization (ACO) spoke about the issue of some Providers reporting four diagnosis codes per visit.  At first, I didn’t think anything of it but then it dawned on me.  It is all about money.

Without going into actuaries, risks and costs formulas the point is simple, healthier individuals use less resources. This means that if you simply use a few codes you are telling Payors (insurance companies and Medicare) that your patients are healthier than others been seen by Providers that use multiple codes. As a result, these Payors consider your risks as less and allocate less money to your panel. In short, you end up receiving less money than other Providers that are doing the same work except for adding some additional codes to their notes and billing documents.

But even if you add more diagnosis codes, you may still receive less money if you don’t let these Payors know about it.  This means that documentation is important but it is worthless unless you include these codes in your billing documentation and transmission. You may think that this is already taken care of, but the reality is that some electronic health records were programmed to send just a few of the diagnosis codes you entered in the note.

Electronic health records are quite particular in their capabilities and there is a possibility that during the setup they were programmed to send only four diagnosis codes. This is a simple fix that you wouldn’t know needs to be taken care of unless you look into it. We highly recommend that you check this particular setup and adjust, if needed, to send the maximum number of diagnosis code possible.

For those that use billing companies to send your claims I encourage you to contact your billing representative and ask them to check their settings and make sure that whenever possible they are sending at least 12 diagnosis codes.

Times are changing and we cannot take anything for granted so stay informed and if needed as for assistance from competent professionals.