General Surgery Coding Alert

Test your coding knowledge.  Determine how you would code this situation before looking at the box below for the answer.
Question: Frequently, a physician will send a patient to us with what they feel is a palpable breast mass. The mammograms/ultrasound are negative. Examination reveals no masses but normal breast tissue. What diagnosis code do I use?

Ellen Simmons
Lansing, Mich.

Answer: This question neatly describes a common ICD-9 dilemma: There are no codes for "rule out" or "suspected" conditions. Generally, says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, this means you must code the signs or symptoms, such as 782.2 (localized superficial swelling, mass, or lump). But in the case you describe, the patient actually doesn't have a lump that your surgeon can detect either by palpation, mammogram or ultrasound.
 
Without any signs or symptoms, you certainly don't want to use an unfounded diagnosis code that may follow the patient for years. This leads coders to the "V" codes, but you know these codes probably will result in being denied payment because they may not show medical necessity. The doctor provided services in good faith based on a suspected condition, and deserves to be paid.
 
The solution to this dilemma is to remember that the primary ICD-9 code should reflect the main reason the patient presented for services, which was indeed a lump (782.2), although it may have been misperceived or subsided in the interim. Sandham also recommends adding a secondary code to indicate the findings after examfor example, V65.5 (person with feared complaint in whom no diagnosis was made [feared condition not demonstrated]). This code helps to describe the evolution of the physician's evaluation in this encounter, Sandham says.