As you can see, having a clear documented problem list is essential to coding. It is critical to have the right diagnoses specified in the chart so that you can associate them with office visits. For example, if someone has hypertension and diabetes, you might be tempted to give the shorthand notations “bp and sugars up” in your assessment and plan. However, elevated blood pressure has many meanings and many ICD9 codes. Some insurance plans will not pay for extensive testing for someone with “bp up,” but will cover 401.9 (benign hypertension). “Cough” may not be sufficient to justify a 99214, but “pneumonia” would probably justify it. Having the right ICD-9 code is critical to coding correctly.
Also, many labs require a specific diagnosis (i.e., an ICD9 code) to link to their test. Having the appropriate ICD9 code from the start will reduce the number of phone calls you get from angry patients. “You didn’t tell me that the bloodwork would cost $500! My insurance says they aren’t going to pay for it! I’m never coming back to your clinic! And your tie is ugly!”
Medical Coding and Billing For Residents 