To establish claim and medical bill liability, WSI requires a provider submit a specific diagnosis code reflective of the injury treated. This requirement aligns with General Coding Guidelines (4) and (18), published in the ICD-10-CM Official Guidelines for Coding and Reporting. These General Coding Guidelines indicate:
"Specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition…. Diagnosis codes describing symptoms and signs are acceptable for reporting only when the provider has not established a related, definitive (confirmed) diagnosis.”
WSI most commonly encounters improper diagnosis coding when a provider assigns a standalone diagnosis code of “pain”, and the medical record indicates a more specific diagnosis is available. While pain may be a relevant sign or symptom resulting from a work injury, it is not a specific condition for which WSI accepts liability. Consequently, receipt of a service coded with “pain” as the only diagnosis may result in a prolonged claim adjudication timeframe as well as a bill reimbursement denial.
The following is an example of reporting a diagnosis with the highest level of specificity: WSI receives a medical bill with attached documentation for an initial visit following a work injury. The worker was lifting a box when they felt something pull in their lower back, followed by aches and pains. The signs and symptoms reported in the medical record include muscle swelling over the lumbar region. The diagnosis indicated in the medical record and reported on the medical bill is M54.5 for lumbar pain. A more appropriate diagnosis, based on the evidence in the medical record, would be S39.012 for a low back strain.
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