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Importance of correct ICD-10 coding for better medical billing

11-May-2021

When submitting a claim to the medical aid you need to indicate on the claim what treatment or service was delivered to the patient (the tariff code) and the diagnosis which prompted this treatment (the ICD-10 code/s). This article explores the importance of correct ICD-10 coding to ensure that you...


When submitting a claim to the medical aid you need to indicate on the claim what treatment or service was delivered to the patient (the tariff code) and the diagnosis which prompted this treatment (the ICD-10 code/s). This article explores the importance of correct ICD-10 coding to ensure that your claims are processed quickly and accurately.

What is ICD-10 coding?

ICD-10 coding is the International Classification of Diseases system. It is a method of translating medical terminology into codes. ICD-10 coding evolved from a series of classifications that was revised several times over the last century. Work on the ICD-10 coding standard started in 1983 by World Health Organisation (WHO) and ICD-10 coding was released for use in 1992.

ICD-10 coding is used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with medical care and treatment (in or out of hospital). There are 69,000 ICD-10 diagnosis codes.

ICD-10 coding enables easy storage, retrieval, and analysis of data. It is the foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions.

WHO is responsible for maintaining the ICD-10 coding every 10 to 15 years.

Importance of coding the primary and secondary ICD-10 codes correctly

There are several instances where more than one ICD-10 code is required to correctly describe a patient’s condition or disease.

The South African definition of a Primary or Main diagnosis is: the Main condition is the condition which is responsible for the patient’s need for treatment or investigation. The Secondary diagnoses are the other conditions that were either present on admission and directly affect the care given for this visit, or developed as a direct result of the Primary diagnosis.

For example, a patient may have an irregular heart rate as a chronic disease and goes to casualty with chest pain. The primary code will be the irregular heartbeat and the secondary code will be the chest pain.

It is important to get the sequence of ICD-10 coding correct, as the scheme has the right to ask for reports if it appears to be a new condition, which will delay payment. Some codes may also need to have a cause code as per SAMA. If it appears that there is no cause code or the cause code is in the incorrect sequence, the medical scheme may reject the claim.

Prescribed Minimum Benefits and ICD-10 coding

Prescribed Minimum Benefits (PMB) are a set of defined conditions to ensure that most medical scheme members have access to certain minimum health services. The aim is to provide members with continuous care to improve health and general well-being and to make healthcare more affordable.

To get accounts paid from the PMB benefit can be a lengthy process. It is important that the ICD-10 code listed is the Primary condition and that it is classified as a PMB condition. There is a limited set of 270 medical conditions and 25 chronic conditions that was set out by the WHO that are listed PMB conditions.

Dealing with ICD-10 related payment delays

  • It is important to have a system in place to track rejections and correct medical coding problems quickly.
  • Ensure your staff are professionally trained and use the correct ICD-10 codes.
  • Ensure you staff understand the most common coding issues (incorrect codes, PMBs, primary and secondary codes).
  • Ensure your practice management software is up-to date.
  • Ensure your practice management software has the functionality to code your claims correctly.

Using a Medical Bureau to manage your practice billing

A medical bureau administers and manages medical claims on behalf of their clients who are healthcare professionals. Medical Bureaus work with medical coding issues on accounts all the time, and can quickly identify problems, correct and resubmit.

It is the responsibility of the medical bureau to keep up with the latest tariff codes and ICD-10 codes introduced by SAMA and the WHO, so that they ensure fast turnaround on claims processing.

This results in a much shorter turnaround time in claims being submitted and paid for. It also allows the healthcare professional to focus more on their practice rather than spending time on administration. The benefits of faster payment and more free time are the key reasons that healthcare professionals use a medical bureau such as Synchramed.

Contact Synchramed today and enjoy fewer administration headaches and more free time!

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