Health Care Financing Administration's Coding and Reporting Requirements for Physician Billing

Why This Topic Matters

Understanding this guidance helps billing and coding staff interpret physician documentation consistently when preparing claims. It also clarifies the broader reporting categories and documentation situations that can affect diagnosis selection, sequencing, and claim acceptance under legacy Medicare rules.

Article Sections

1. Use of ICD-9-CM

   Introduces the ICD-9-CM conventions and where to find foundational guidance within the system. It emphasizes general search and reference practices for diagnosis coding.

2. Coding guidelines for physician billing - valid ICD-9-CM codes

   Describes the general approach to identifying diagnosis-related codes for physician billing. It outlines the scope of diagnosis reporting and the use of supplementary classifications.

3. Coding guidelines for physician billing - sequencing

   Explains how diagnosis order is handled on the claim and how the primary reason for the encounter is selected. It also notes the handling of additional reported conditions.

4. Coding guidelines for physician billing - specificity

   Covers the need to report the most specific available diagnosis code and the impact of code structure on claim reporting. Examples illustrate the general principle of specificity in coding.

5. Coding guidelines for physician billing - probable, suspected, etc

   Addresses how uncertain or unconfirmed diagnoses are treated in physician billing. It contrasts physician reporting with inpatient hospital coding practices and includes a referral-related example.

6. Coding guidelines for physician billing - chronic disorders

   Discusses recurring reporting of chronic conditions when ongoing care is provided. It includes an example of repeated treatment across multiple visits.

7. Coding guidelines for physician billing - diagnostic services

   Explains sequencing for ancillary diagnostic services and the role of examination-related V codes. It includes examples involving radiology and pathology referrals.

8. Coding guidelines for physician billing - therapeutic services

   Describes reporting for ancillary therapeutic services when performed during an encounter. It provides an example involving rehabilitation-related services.

9. Coding guidelines for physician billing - surgery

   Outlines how to identify the diagnosis associated with a surgical service and how postoperative information may affect reporting. This section focuses on the general sequencing approach for surgery-related claims.

10. Coding guidelines for physician billing - coexisting conditions

    Explains which additional conditions should be reported when they are present during the encounter and affect care. It distinguishes current problems from historical or resolved conditions.