Diagnosis codes are also known as ICD-9 (International Statistical Classification of Diseases and Related Health Problems, Version 9) codes.
These codes are used to describe illnesses or injuries, and their severity without having to always write everything out. As of October 1, 2015,
this will change to ICD-10, which will really make things more complicated and there will be some problems for a while, but eventually everyone will
get used to it.
Every medical claim that's submitted to anyone for payment has to include a diagnosis code, and that diagnosis code has to be related in some
way to the treatment you're receiving. Diagnosis codes begin with 3 numbers, and in most cases have a one or two digit category after the main
number to help be more specific as to the nature of the illness or injury.
For instance, the diagnosis code for diabetes could be listed at 250, or
250.00, because there are subcategories that follow diabetes, and they have their own meanings.
Insurance companies can deny coverage of procedures if the diagnosis codes are either incorrect or not definitive enough. In some instances,
you might be required to sign off on an advanced beneficiary notice if your medical practitioner knows your procedure
won't be covered.
In other circumstances, diagnosis codes might be needed in order to get an approval or authorization from your insurance company. Once
again, the diagnosis code and procedure codes must match up to get approval for the procedure.
However, sometimes even this isn't enough.
To use a personal story, one time I needed an approval for a procedure to relieve some pain I was
having. The insurance company kept denying the authorization, and my physician was at a loss. I called the insurance company and asked
them what the issue was. I was told that the procedure was considered cosmetic. I indicated that I was in pain, and that's why I needed to
have the procedure done in the first place. I was then told that the physician had to submit an extra diagnosis code indicating that I was in
pain, and then the approval would be granted, and they told me which code to tell him to use. I called him, his office staff did what they were
told, and the approval was finally granted.
A patient's account can have multiple diagnosis codes, and probably should have them. Physicians are notorious for not putting down
all the diagnosis codes which may apply to your condition, which is a very common reason why some services may be denied. If you
find this happening, a good place to check would either be your physician's office or the hospital's medical
records office, because,
unfortunately, hospital medical records will sometimes code an account incorrectly, and, as it applies to some outpatient services, will use
the code a physician sent rather than changing it because the physician's word is supposed to be golden. A good medical records department
will contact the physician's office when they see something blatantly incorrect, but not always.