Cardiology Coding Alert

Signs and symptom ICD-9 codes should be used to provide medical necessity for a procedure or service when there is not a more specific diagnosis available to the cardiologist. Although physicians are trained to look for a specific diagnosis, sometimes a patient may have a complaint that cannot be diagnosed right away.

In some cases, the complaint may be gone by the time the cardiologist evaluates the patient; in others, no definitive diagnosis can be ascertained before lab tests are returned.

In these situations and many others, signs and symptoms should be reported instead of suspected, or rule-out, diagnoses. This can be difficult for cardiologists, because for inpatient billing, they are instructed by hospitals to use suspected and rule-out diagnoses, and it is appropriate for the hospital to bill it as if the patient has that diagnosis. This, however, doesnt apply to physician component billing, whether inpatient or outpatient, and switching gears may be confusing for physicians.

Section 16 of the ICD-9 manual includes many such signs and symptoms codes (780-799.9), which should be used if a diagnosis is not available or until a diagnosis can be proven. Similarly, these codes should be used when a pathology report returns negative.

Physicians are not allowed to use suspected or rule-out diagnoses, says Cynthia Thompson, CPC, a coding and reimbursement specialist with Gates, Moore, an Atlanta-based consulting firm. So without a specific diagnosis, they have to use the signs and symptoms that brought the patient to the office and that prompted the physician to perform the rule-out tests.

Often, the cardiologists assessment and plan states that certain tests are being performed to rule out other conditions, Thompson says. But rule-outs should never be used to code physician services, so the only thing left for the physician to code is the sign or symptom that brought the patient to the office in the first place and that led the cardiologist to order or perform the rule-out test.

A patient also may come to the office with a complaint, but after the examination, the cardiologist finds nothing wrong. For example, the patient may be referred to a cardiologist by a primary-care physician following complaints of shortness of breath. During the examination, however, the cardiologist is unable to determine the cause.

In such a scenario, coding what was found (i.e., nothing) is inappropriate. Instead, the sign or symptom (i.e., shortness of breath, 786.05) should be coded to provide medical necessity for the exam. Of course, if, during the course of the examination, the cardiologist finds something that is more specific, then that diagnosis code should be used. But lacking a specific finding, it is correct and appropriate to bill using the symptom described by the patient as the reason for the visit.

Avoid Labeling the Patient

In some situations, using signs and symptom codes not only provides more accurate coding but also avoids inappropriately labeling the patient, which can have long-term consequences. For example, a 32-year-old healthy woman comes into the cardiologists office because of palpitations. The cardiologist takes the womans blood pressure, which is rather high at 150/94. The patient, however, has no history of hypertension.

To check the palpitations, the cardiologist also does an ECG, which indicates the palpitations are benign. The patient says her blood pressure always is elevated when she sees a physician, whereas at home its never more than 130/80; she also reports drinking 14 cups of coffee daily.
The cardiologist also suspects white coat syndrome, as the patient may be particularly anxious because this is her first visit to a cardiologist. The patients mother has a blood pressure kit, so the cardiologist sends her home with instructions to check her blood pressure for the next two weeks. Two weeks later, the patient reports normal blood pressure and no more palpitations.

When the cardiologist bills the original encounter, it would be incorrect, and highly damaging to the patients ability to obtain health insurance, to give the patient a diagnosis of hypertension. Often hypertension is used incorrectly to mean high blood pressure, but the two are not synonymous; high blood pressure is a symptom, whereas hypertension is a serious and typically lifelong medical condition. In this situation, the correct ICD-9 code to associate with the visit is 796.2 (elevated blood pressure reading without diagnosis of hypertension). The signs and symptoms code for palpitations (awareness of heart beat), 785.1, also should be included.

Identify Medical Necessity for Visits, Tests and Consults


There usually is a reason in the history of present illness or in the chief complaint for the patients visit, Thompson says, and those symptoms justify the medical necessity of the visit. However, she notes, the medical record of the visit must match the signs and symptoms code used when billing for the evaluation and management (E/M) visit. Typically, Thompson says, this would be documented as the patients chief complaint or in his or her history of present illness, key components when taking a patients history during an E/M service.

You cannot make up signs or symptoms after the fact, Thompson says. You have to use the signs or symptoms documented in the patients medical record. If the physician noted the patients complaint as shortness of breath, then 786.05 should be used.

Note: If the visit ends with a specific diagnosis, the sign or symptom would become the secondary code, while the diagnosis would become the primary code.

A sign or symptom also can provide medical necessity for tests ordered by the cardiologist. For example, if a patient complains of chest pain, the cardiologist is likely to perform an ECG; when the ECG is billed, 786.50 (chest pain) is the associated ICD-9 code.

Furthermore, it is sometimes easier to justify billing for a consult using an undiagnosed sign or symptom rather than an established diagnosis. Had the patient had a known disease, the carrier might think that a transfer of care had occurred and reclassify the service as a new patient visit rather than a consult, says Terry Fletcher, BS, CPC, a coding and reimbursement specialist in Laguna Beach, Calif., For example, a 62-year-old woman is seeing the cardiologist at the request of her primary-care physician, who performed a treadmill test that shows 1.5 mm ST segment depression.

When the patient arrives to see the cardiologist, We do not have a diagnosis. We cannot say the patient has coronary disease. But she does have an abnormal stress test, says Marko Yakovlevitch, MD, FACC, chief of cardiology at Northwest Hospital in Seattle.

The abnormal test result indicates the medical necessity for the consult, because it shows the cardiologists opinion was required to work up the patient to determine diagnosis and course of treatment.

Tip: When using signs and symptoms codes from the ICD-9 manual, be on the lookout for any specific exclusions. Also remember that many, but not all, diagnosis codes require a fifth digit.

Boost Levels of E/M Service

The signs and symptoms codes in the ICD-9 manual not only support the need for tests, they also can justify higher levels of E/M service, Thompson says, noting that the medical decision-making portion of the E/M services often is boosted when the physician has only a sign or symptom to work with due to the undefined nature of the complaint. Often, you can cite medical decision-making of moderate or high complexity when using signs and symptoms codes, because the situation increases the number of diagnoses/management options portion of the decision-making category, Thompson says.

The other two components of medical decision-making table of risk and tests ordered and reviewed also are likely to be higher when there is no specific diagnosis, says Kathleen Mueller, RN, CPC, CCS-P, an independent coding and reimbursement specialist in Lenzburg, Ill. When a problem is undiagnosed, it often means the doctor will have to order tests to try to determine the patients problem, Mueller says. After all, she notes, a specific diagnosis is less likely to call for a wide variety of tests than a sign or symptom, because the cause of the symptom is unknown and needs to be discovered.

And since diagnostic procedures ordered is one of the three components of the table of risk, the level of risk may increase because the highest single category of the risk table determines the entire risk component.

Signs and symptoms often relate to more than one health issue in a patient, which also may increase the complexity of the diagnosis and, therefore, the medical decision-making by the cardiologist. In addition, the patient may have multiple signs and symptoms, which may further boost decision-making and probably history levels as well.

For example, a cardiologist sees a 45-year old hypertensive male smoker with the following signs and symptoms: syncope (780.2), palpitations (785.1) and chest pain (786.5x). Six months earlier, the patient presented to the hospital with chest pain, was admitted and ruled out for myocardial infarction. Some lower extremity edema subsequently was noted. Now the patient appears to be having episodic hypotension; the palpitations, meanwhile, could indicate a cardiac arrhythmia. Furthermore, the chest pain described by the patient also could indicate coronary disease, particularly in view of the patients history of hypertension and smoking. So the cardiologist now also is concerned that if the patient is having a cardiac arrhythmia and also has coronary disease, he could be having ventricular tachycardia, a life-threatening arrhythmia, says Yakovlevitch. On the other hand, he says, the patient could have a pulmonary embolus (also life-threatening), or a bleeding peptic ulcer.

This is high-level decision-making. If the patient has ventricular tachycardia and ischemic coronary disease, and this is not recognized or treated, the patient may die suddenly, Yakovlevitch says.

The cardiologist orders an electrocardiogram (ECG) and performs a stress echo. Electrolytes and a complete blood count (CBC) are ordered, and the hospital records from the previous visit are examined.

The signs and symptoms, combined with the patients history, greatly increase the number of differential diagnoses, satisfying the first of three components for high complexity medical decision-making. (The fact that most of the presenting signs and symptoms are new problems also satisfies this requirement.) In addition, the cardiologist has ordered and reviewed enough tests and records to meet the second component amount and complexity of medical tests and records ordered and reviewed.

With two of the three components in the highest category, the medical decision-making of this visit qualifies as high-complexity. As a result the visit would qualify as high-level decision-making and, because the history is comprehensive, coding would be a level five E/M established patient office visit.

Typical Cardiology Signs and Symptoms 780.2 syncope and collapse 782.3 localized edema, not otherwise specified 785.0 tachycardia, unspecified 785.1 palpitations 785.2 undiagnosed cardiac murmurs 785.3 other abnormal heart sounds (cardiac dullness, increased or decreased; friction fremitus, cardiac; precordial friction) 786.0x dyspnea and respiratory abnormalities (e.g., shortness of breath) 786.5x chest pain 794.30 abnormal function study, unspecified 794.31 abnormal electrocardiogram (ECG) 796.2 elevated blood pressure reading without diagnosis of hypertension