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General Surgery Coding Alert

Medicare Carriers Instructed To Accept Post-Test Diagnoses

Published on Thu Nov 01, 2001

Medicare carriers have long differed on whether physicians who perform diagnostic tests should report the diagnosis revealed by the test or the sign or symptom that prompted the test. Now CMS has ruled that the post-test diagnosis should be used.
 
A CMS transmittal (AB-01-61) issued on Sept. 26 states: "If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis."
 
If the test is normal, surgeons should use the sign or symptom that prompted the test. The transmittal also reiterates the longstanding ICD-9 guideline that rule-out diagnoses are not permitted. Therefore, surgeons should avoid using terminology that reflects uncertainty, such as "probable," "suspected," "questionable" or "rule-out."
 
Diagnostic tests for screening, however, are not permitted, even if the test reveals a problem that requires further treatment. Physicians are instructed to report the reason for the test (i.e., screening, V73.x-V82.x) as the primary diagnosis. The results of the test, whether negative or positive, may be recorded as additional diagnoses.
 
Note: Section #4317(b) of the Balanced Budget Act specifies that referring surgeons are required to provide diagnostic information to laboratories or other testing entities. The information may be communicated in a written document, an e-mail or a phone call.
 
The pre- or post-test diagnosis issue has long troubled coders, who are trained to code to the highest level of specificity. Some payers, such as WPS, the Part B carrier in Illinois, Michigan, Minnesota and Wisconsin, have insisted that physicians link pretest signs or symptoms to their diagnostic test CPT codes, even though the post-test diagnosis is typically more specific and accurate.
 
The CMS instructions that post-test diagnoses should be used means that coding such tests is similar to coding biopsies. When the surgeon takes a biopsy and sends it to the laboratory, the claim form (containing the linked diagnosis) should not be sent until the pathology lab has issued its report and the state of the sample is known. Some offices circle a "diagnosis" choice of  "WAIT" to make sure the pathology diagnosis is back before the claim is processed.

Surgeons With In-House Labs Are Most Affected

For reimbursement, the diagnostic test issue affects surgeons less than other specialists, such as radiologists and cardiologists, who perform and interpret an array of tests. However, surgery practices with in-house vascular or mammography labs that treat Medicare patients in states where pretest diagnoses were requested are likely to welcome the CMS ruling, particularly because vascular laboratories have been targeted and are now highly scrutinized, says Arlene Morrow, CPC, a general surgery coding and reimbursement specialist in Tampa, Fla.
 
For example, a Minnesota surgeon whose practice includes a vascular lab treats a 68-year-old male patient complaining of pain in his left leg. The surgeon performs an extremity arterial study (93922, non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral [e.g., ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement]), which reveals obstructions causing claudications in the artery. The surgeon schedules the patient for a percutaneous transluminal angioplasty.
 
Prior to the CMS transmittal, the correct diagnosis code reported to WPS to provide medical necessity for the extremity artery study would be 729.5 (pain in limb). Effective Jan. 1, 2002, the surgeon can use the post-test diagnosis (443.9, peripheral vascular disease, unspecified; intermittent claudication, not otherwise specified), Morrow says.
 
The change may not have significant reimbursement ramifications for surgeons. In the example above, for instance, leg pain may be an acceptable diagnosis for an extremity artery study. In other cases, the carrier may not have issued a local medical review policy (LMRP) on extremity artery studies that restricts certain diagnoses. The new CMS guideline applies a basic coding principle that diagnosis and procedure codes be selected to the highest level of specificity to procedure billing, and allows the most appropriate diagnosis to be linked to the appropriate CPT diagnostic test code, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.
 
This principle should also apply to other diagnostic treatments, such as colonoscopies and upper GI scopes, when appropriate, Cobuzzi says.
 
Note: Incidental and unrelated findings should not be reported as the primary diagnosis for the diagnostic test or service, even if the findings are more serious than the sign or symptom that prompted the test, according to the CMS transmittal.

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