Neurology & Pain Management Coding Alert

You can (and often should) use signs and symptoms as a primary diagnosis

Here's a coding rule to live by: In the absence of a definitive diagnosis, always report signs and symptoms to support medical necessity for services the doctor provides.
 
If the neurologist confirms a diagnosis, he should report that diagnosis instead of the signs or symptoms that prompted the procedure, according to CMS program memorandum AB-01-144. But that doesn't mean you can't report signs and symptoms, when necessary.
 
If the neurologist doesn't confirm a diagnosis, you should still report the signs and symptoms, says Alice Church, CCS-P, coding and reimbursement analyst for Wolcott, Wood & Taylor Inc. and chief billing officer for the University of Illinois Hospital Physicians in Chicago.
 
For example: During an initial consult with a new patient, the neurologist suspects a diagnosis of carpal tunnel syndrome (ICD-9 code 354.0). Until testing has confirmed that diagnosis, however, you should rely on signs and symptoms to justify medical necessity for any services the physician provides.
 
Typical signs and symptoms indicative of carpal tunnel syndrome include 719.44 (Pain in joint, hand), 726.4 (Enthesopathy of wrist and carpus), 782.0 (Disturbance of skin sensation) and 782.3 (Edema).
 
Case 1: Confirmed diagnosis. The neurologist conducts electrodiagnostic testing (such as nerve conduction studies 95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study and/or electromyography 95860, Needle electromyography; one extremity with or without related paraspinal areas) and confirms a diagnosis of carpal tunnel syndrome. In this case, you should report 354.0 as the primary diagnosis and list the signs and symptoms as secondary diagnoses.
 
Case 2: Inconclusive evidence. Once again, the neurologist conducts the appropriate testing, but the results are inconclusive or negative for carpal tunnel syndrome. In this case, you should rely on the signs and symptoms only to establish medical necessity for the tests the neurologist conducted, as well as any E/M service he or she provides. Stay Away From 'Rule Outs' ICD-9 coding guidelines state that you should not report "rule-out" diagnoses in the outpatient setting. This approach avoids labeling the patient with an unconfirmed diagnosis while still allowing for reimbursement for the physician even if testing cannot establish a definitive diagnosis, Church says.

For example: Returning to the above case, you shouldn't claim a diagnosis of 354.0 in the hopes of receiving payment if the neurologist has not or cannot definitively establish a diagnosis of carpal tunnel syndrome. Rather, the neurologist's documentation should be strong enough to support the claim with the signs-and-symptoms diagnoses alone, regardless of the outcome of diagnostic testing.