Ask the payment expert ... about matching diagnoses codes

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Patricia Boyer, MSN, NHA, RN
Patricia Boyer, MSN, NHA, RN

How important is it that diagnoses coded in Section I of the MDS match what is being billed on the UB-04?

There are several “look back” periods for Section I of the MDS. The first is that the diagnosis has to be physician-documented within the last 60 days. This could be admission information for a Medicare resident.

The second is that the diagnosis has to be active within the last seven days. Your MDS is based on the diagnoses that are active during that specific seven-day “look back” period. Your UB-04 is based on the calendar month you are billing. So, the two might not directly match. 

However, it stands to reason that if you are billing for a service, there should be a diagnosis that shows the need for that service. And, in most cases, that diagnosis was present when the MDS was completed. 

As an example, if someone is receiving speech therapy during the billing month, a diagnosis of aphasia, dysphagia or another speech or swallowing problem should exist.  In addition, the MDS should show the deficit in communication, swallowing or cognition. 

A word of caution: If you are providing speech therapy for cognitive issues, you need to be able to show that the deficit is related to the hospital stay. Again, it also must correlate with what is coded on the MDS.  

Medical reviewers now have a lot of information available to them when they are reviewing a claim. They have the Common Working File, the MDS, the UB-04 and the medical records you submit.  RAC automated reviews will only have the electronic information to review. If all the pieces do not say the same thing, you need to justify the care you provided.   

You will have a much better outcome of any medical review if you think about these areas before you submit the bill.