Cardiology Coding Alert

Many cardiology coders have the false impression that they must use a pretest diagnosis when they bill for a test, such as an echocardiogram or EKG.

As long as the medical necessity requirements of the tests are met, either signs/symptoms or final results of tests may be used to obtain reimbursement. But using the post-test diagnosis is preferable because, according to the Health Care Financing Administration (HFCA) guidelines, diagnoses should be coded to the highest degree of specificity.

Suppose for example a family physician sends a patient with a diagnosis of syncope (780.2) to the cardiologists office for an echo. The test uncovers an ischemic cardiomyopathy. Nevertheless, some coders will attach the syncope diagnosis to the procedure code for the echo. However, that code may not provide medical necessity for the test and, therefore, reimbursement will be denied.

The rationale in the coders mind for the incorrect coding is that the diagnosis that prompted the test to be ordered in the first place should be the one attached to the charge for the test.

However logical this may seem, it contradicts the HCFA guidelines and often will result in denials for tests that should have been reimbursed. Some coders call using the diagnosis from the results of a test back-coding and think it is improper.

The uncertainty over diagnosis codes for tests has been getting worse in the last 18 months, says Dari Bonner, CPC, CPC-H, CCS-P, president of Xact Coding and Reimbursement in Port St. Lucie, FL.

Bonner points to a proverbial mountain of guidelines from Medicare and the American Medical Association, all of which maintain that it is perfectly legitimateand usually preferableto use the results of the test as the diagnosis to accompany the charge for it.

Post-Test Diagnosis

According to Medicare guidelines on the use of ICD-9 codes revised on Oct. 1, 1996, physicians may not use rule outs or suspected as a reason for performing a diagnostic test. In other words, the test cannot be billed simply to rule out a disease, or because an illness is suspected. Section H of the official ICD-9 CM guidelines for coding and reporting states: Do not code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosis. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results or other reasons for the visit.

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in North Augusta, SC, says it is significant that the following paragraph states this is contrary to the coding practices used by hospitals and medical record departments for coding the diagnosis of hospital inpatients. According to Callaway-Stradley, the inpatient coding customs may well account for [...]