ED Coding and Reimbursement Alert

When reporting each is appropriate

You've heard the story both ways: Some coders say reporting signs and symptoms in addition to a primary diagnosis is perfectly legitimate, while others think the definitive diagnosis should be the only word. Answer your tough diagnosis questions with these expert opinions.

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Many coders believe that if your physician issues a final diagnosis, you should not report the associated signs and symptoms, because they think you're asking for extra reimbursement. But others disagree. "Signs and symptoms are appropriate to use, even if a definitive diagnosis is stated," says Robert La Fleur, MD, FACEP, president of Medical Management Specialists in Grand Rapids, Mich. "Use whatever is available in the record to indicate why the patient came to an emergency department (ED)."  

For example, a 45-year-old man presents to the ED with a complaint of severe chest pain. The physician performs a history, review of systems, physical examination, and relevant tests, including an electrocardiogram and chest x-ray. After the tests and exam, the doctor reports indigestion as the final diagnosis.

Since the initial reason the patient visited the ED was chest pain, you should report this as the primary diagnosis. CMS program memorandum AB-01-44 supports this approach, given that some payers have software that won't look beyond the first diagnosis or won't apply the second diagnosis to all the services your physician provided.

Don't Leave Room for Doubt

If you fail to report signs and symptoms in addition to the primary diagnosis, you may run into problems with payers, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Evanston, Ill. "The final diagnosis may not describe the reason for the encounter," she says. "Classic examples are chest pain that ends up being just indigestion, or severe abdominal pain that ends up being constipation."

The ED is unique in that the necessity for seeking service there is different than it is in other places, Gilhooly says. "The ICD-9 coding rules are very clear that the primary code that should be reported is the code that reflects the reason for the encounter." The reason a patient presents to the ED, rather than to a primary-care physician or a specialist's office, is her initial complaint (such as abdominal pain), regardless of what the physician determined as the cause of that pain, Gilhooly says.

This distinction makes painting an accurate -- and complete -- picture all the more important on your claims.

Look at the Big Picture

One helpful rule is to consider your decisions from the insurance company's point of view. In the example in which the chest-pain complaint is only indigestion, for instance, many insurers' standards won't deem indigestion a reasonable purpose for seeking ED treatment, says Sandra Pinckney, office manager and coding supervisor at Certified Emergency Specialists in Grand Rapids, Mich. "However, when [the carrier] realizes the patient had chest pain, that does seem reasonable to them ... as to why the patient is here -- and thus helps them to see the need to reimburse us for this service," she says.

And because many commercial carriers only recognize the primary diagnosis code, you must be sure to place the code that represents the reason for the visit in the right spot, Pinckney adds.

But you should ultimately use your best judgment: In some cases, the patient's "signs and symptoms will be more interchangeable -- such as abdominal pain and cholelithiasis, or ear pain and otitis -- so either code really paints the picture well enough for the insurance company to understand why the patient felt emergent treatment necessary," Pinckney says. In these situations, you should report the definitive diagnosis so the carrier will have no trouble appreciating the need for ED care.

Streamline the Process for Doctors -- and  Yourself

Let's say the ED physician issues a final clinical impression, and fails to include signs and symptoms or additional diagnoses on the write-up. Feed this chart back to the doctor for question-and-answer and educational purposes, says Mike Granovsky, MD, CPC, FACEP, chief financial officer for Greater Washington Emergency Physicians in suburban Maryland.

"It is a potential liability for the coder to pull diagnoses from the differential that the doctor has not validated as conclusive," Granovsky says. For example, a 78-year-old patient presents to the ED with dizziness, which could lead to several different diagnoses: vertigo, transient ischemic attack (TIA), or weakness. The physician performs multiple inconclusive tests, including a head computed tomography scan. After discussion with the patient's primary-care physician, the ED doctor starts the patient on aspirin as part of an anti-stroke program.

"In this case, the physician's only documented final diagnosis is dizziness. Although the possibility of TIA is in the differential and contributes to the medical decision- making area, the doctor did not feel conclusive enough about the presentation to call [the patient's condition] anything other than dizziness," Granovsky says. You should code only the dizziness -- not the TIA, he says.  And don't forget that while you may reiterate what the physician clearly documents in the chart, you should be careful not to interpret or extrapolate from clinical information you receive.

But the story doesn't end there, because "given the opportunity, many doctors will include the signs and symptoms in the final diagnosis area of the chart," Granovsky says. One easy way to provide this opportunity conveniently is to set up a user-friendly patient encounter form that gives physicians space specifically designated for this information. This way, you'll spend less time hunting them down when you need more information.