WARNING: If you do not read all the future consultations, then you stand the chance of being a “one-and-done” with the lawyers. You have to learn to speak their language of admissibility.
We have all been taught in our professional education how, through a proper history, evaluation and review of testing, to render a proper diagnosis. Picking one, at times, may seem like an arbitrary process and to have little bearing on your treatment plan. Nothing in that statement is remotely close to reality. The impact making diagnoses has on your patients, referral sources and your practice’s income may be greater than you realize.
First, I consult many practices from hospital-based to clinic-based to small offices. The array of doctors are from every field of healthcare and every doctor has one common trait. The majority, if not all, pay little attention to the diagnosis (with the exception of the surgeon who needs a specific diagnosis to ensure approval for surgery where a certain code needs to be used).
Secondly, I have taught medical coding at the State University of New York at Stony Brook, Department of Health Science and Technology, to future hospital administrators, and have fully come to understand that doctors have no training in the understanding or proper utilization of the ICD-9…and how to positively impact their practices by using the right codes. In fact, most doctors have their non-professional billing staff choose a diagnosis for them, leaving them exposed to serious licensure and malpractice issues if the non-professional staff makes a mistake. What’s even more troubling is that the doctor rarely checks the choices that their non-professional staff members make.
The World Health Organization Collaborating Center for the Classification of Diseases for North America was established in 1976 to represent the United States and Canada in international activities related to the study and revision of the International Classification of Diseases and Health Problems (ICD). The National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services are the U.S. governmental agencies responsible for overseeing all changes and modifications to the ICD-9-CM. This is important to know because those governmental agencies rely on input from state organizations, hospital agencies, doctors and insurers to affect change. With that change, there is political and financial pressure to protect the rights ($) of those involved. All too often, those with the most money, as in all walks of life, exert the most influence. In the group listed above, the insurers are the group with the most money. With that being said, let’s go back to the diagnosis. I recommend HJ Ross Co. Doctors can consult with them for $9.99 per month.
All diagnoses are not the same. For instance, if you take a problem in the lumbar spine, you have numerous choices for diagnosis. Let’s look at 4:
M62.838 Spasm of the Lumbar Musculature
M54.5 Lumbago-Lumbar Pain Syndrome
S34.21XA Injury to the Lumbar Nerve Root
S39.012 Lumbar Strain/Sprain
Please notice that I omitted lumbar radiculopathy. I did so because there wasn’t an EMG to conclusively diagnose the evidence of the radiculopathy.
From trauma, you can pick any of the four diagnoses above should there be a complaint of pain and associated clinical findings in the lumbar region. All four would be considered appropriate diagnoses and usually the doctor has been conditioned to choose the last, strain/sprain. There is one very big clinical issue with choosing strain/sprain and in addition, there is one coding issue with choosing strain/sprain. When studying strain/sprain, we understand that there are three grades:
- Grade I Sprain (primary):
Grade I joint sprains cause stretching of the ligament. The symptoms tend to be limited to pain and swelling.
- Grade II Sprain (secondary):
A Grade II joint sprain is more severe partial tearing of the ligament. There is usually more significant swelling and bruising caused by bleeding under the skin.
- Grade III Sprain (tertiary): Grade III sprains are complete tears of the ligaments. The joint is usually quite painful and walking can be difficult.
These are usual and customary descriptions of strains/sprains that have been taught in every healthcare professional school for decades.
Let’s go to the ICD-10. If you look carefully, there is no opportunity for a doctor to choose from the 3 grades, only 1. That is very problematic because you, the doctor, are now not conveying the accurate condition of your patient, and there are significant consequences. The most important consequence is for another doctor that co-treats your patient to not get a true reflection, through diagnosis, of what is wrong with the patient.
The next problem is the insurer. If you follow the IME doctors, the number one diagnosis utilized is strain/sprain. Why? The answer is simply that courts across the country have accepted the strain/sprain diagnoses as transient and will allow them to prevail in the majority of personal injury cases by your diagnosing a transient problem.
In fact, they are correct if you consider only a Grade I strain/sprain. It is within their rights to reach the conclusion that strain/sprain diagnoses are Grade I because you have given them the opportunity to do so through your selection of diagnosis. This will have a negative impact on your patient in the courts should there be a Grade II or Grade III strain/sprain because your diagnosis will not reflect the truth of the condition.
I am not saying you should base your diagnosis on making the lawyer and courts happy or to positively impact your patient’s legal case. I am saying, make an accurate diagnosis with the myriad of choices available to you in the ICD-9 that reflects the true condition of your patient.
A second issue is that of “relative weights.” This is a very little known value to doctors that is placed upon each and every diagnosis. Simply, the higher the relative weight (RW), the longer the hospital stay, the more treatment allowed prior to being IME’d, the more a carrier will allow based upon the RW.
Let’s go back and look at the relative weights of the 4 choices we had to choose from for the lumbar sample above:
M62.838 Spasm of the lumbar musculature RW – 0.57
M54.5 Lumbago-Lumbar Pain Syndrome RW – 0.74
S34.21XA Injury to the Lumbar Nerve Root RW – 0.97
S39.012 Lumbar Strain/Sprain RW – 0.74
Since all four qualify to be chosen based upon clinical findings, why would you choose one that does not accurately describe your patient’s condition (Lumbar Strain/Sprain RW – 0.74) or those with lower relative weights? The answer is simple; I would choose Injury to the Lumbar Nerve Root RW – 0.97.
When I consult practices, I create a grid for them. I take into account all of their most common diagnoses and then go to the ICD-10 and give them choices that make the most sense regarding being accurate in description and the highest relative weight. Unlike healthcare, diagnosing is an exact science based upon your clinical findings. Choose wisely, it will greatly impact your patients, your relationship with the lawyers representing your patients and your practice income.
Note: After I released this consultation, I received many calls and e-mails requesting that I provide a diagnosis sheet with the relative weights attached, to save your office's time in trying to figure it out. Although you can do it on the Internet on your local Medicare provider's Web site, I put together a template to facilitate the process for you. Should you need this service (I apologize for the commercial on the consulting site), go to "forms and templates" on the second toolbar of the consulting site.