It is important to  make sure that your diagnosis codes are correctly identifying the condition you’re that you are treating.  Not to mention it is ‘must’ for your documentation  to a third party payer. Following are the most important tips regarding diagnosis that are so often missed and can mean the difference between a paid claim and a denied, unpaid claim.

1. Be sure to use updated diagnosis codes.  Don’t rely on your old ‘cheatsheet’ for correct diagnosis codes.  Some diagnosis codes require a 5th digit. So be sure to code to the highest specificity.
2. When performing a re-exam or when performing and examination for a ‘new’ problem, be sure to update your diagnosis.   For every new episode, you should show an update in your diagnosis coding.  Even if the change is small, be sure to document the change.
3. When completing a CMS 1500 form, be sure to include at least one diagnosis code in box 21. Major medical carriers require a minimum of one code in box 21, while Medicare (with the exception of First Coast) requires a minimum of two…one for the segmental dysfunction and one for the supporting condition code.
4. Be sure to link your diagnosis to the service you  provide.  This will help to show medical necessity.  For example, when performing an extremity adjustment, your diagnosis should show a condition that affects an extremity area, not a spinal area.

And above all…..DOCUMENT, DOCUMENT, DOCUMENT!!!!!!!