Coding Determinations

3.6.2.4 - Coding Determinations (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) This section applies to MACs, CERT, SMRC, Recovery Auditors, and UPICs, as indicated. ICD-10-CM is used for diagnoses on inpatient discharges and for other services provided on and after the implementation of ICD-10-CM.. ICD-9-CM is used for discharges and other services before that date. The MACs, CERT, SMRC, Recovery Auditors, and UPICs shall determine that an item/service is correctly coded when it meets all the coding guidelines listed in the Current Procedural Terminology-4 (CPT-4), Coding Clinic for ICD, Coding Clinic for HCPCS, and any coding requirements listed in CMS manuals or MAC articles. In certain situations, it is appropriate for contractors to up code or down code a claim (or items or services on a claim) and adjust the payment. When the medical record supports a higher or lower level code, the MACs, SMRC, CERT, UPICs and Recovery Auditors shall not deny the entire claim but instead shall adjust the code and adjust the payment. The MACs, SMRC, CERT, UPICs and Recovery Auditors shall up code or down code when it is possible to pay for the item or service actually provided without making a reasonable and necessary determination or if otherwise specified in applicable CMS medical review instructions. The MACs, SMRC, CERT, UPICs and Recovery Auditors shall not substitute the payment amount of one item or service for a different item or service based on a reasonable and necessary determination. Example situations where it is appropriate to up code or down code a claim are: 1. CBC with diff was ordered and billed but CBC without diff was provided; 2. X-ray with contrast was ordered and billed but X-ray without contrast was provided; 3. E&M level 3 was billed but the medical record supports level 2 (or other level); 4. PPS (DRG/RUG/HHRG) code was billed but the medical records supports a different code; and 5. Quantity of diabetic test strips exceeds limits; for example, quantity was provided for insulin treated but the patient was not insulin treated.