Neurology & Pain Management Coding Alert

When test results are inconclusive, deciding whether to code the symptoms or the suspected diagnosis can cost you if you choose incorrectly. Follow this real-world case to understand your options, whether or not your neurologist provides you with a clear diagnosis.

Review the Case Scenario: The neurologist performed a diagnostic electroencephalography (EEG) study on a teenage girl with complaints of bilateral arm jerks when she wakes up in the morning. The jerking is increasing and is starting to cause her to drop things. The neurologist's EEG report indicates the presenting problem as myoclonic jerks and abnormal EEG findings with clinically confirmed Janz syndrome.

Your first instinct might be to simply report myoclonic jerk symptoms (333.2, Myoclonus) as either the primary or secondary diagnosis code. But first refer to Section IV L. of the ICD-9-CM guidelines, which states: "For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses." You can read the full guidance online at www.cdc.gov/nchs/data/icd9/icdguide09.pdf.

The key is to remember that a definitive diagnosis trumps signs and symptoms. Your coding for this is more straightforward as a result. The neurologist confirmed a diagnosis (Janz syndrome) based on the symptoms (myoclonic jerks) and the results of the EEG exam. Therefore, you should not use 333.2.

In this scenario, you would report 345.10 (Generalized convulsive epilepsy; without mention of intractable epilepsy) as the primary ICD-9 code, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO. with MJH Consulting in Denver, Colo. This supports the medical necessity for the diagnostic study.

Here's why: Janz syndrome, also known as Juvenile Myoclonic Epilepsy (JME), is an inherited disorder characterized by mild myoclonic jerking. Therefore, in this case study, the myoclonic jerking represents a symptom of the patient's condition. Since your neurologist was able to confirm Janz syndrome you can -- and should -- report 345.10.

When your neurologist documents a definite impression you should always code that as the primary diagnosis. If the neurologist performs an EEG because he suspects Janz syndrome, but the EEG is inconclusive or negative, however, you cannot report the Janz diagnosis. Instead, you should simply stick to reporting the patient's documented signs and symptoms that prompted the diagnostic EEG.

Why? Section IV E. of the ICD-9 guidelines supports this coding concept: "Codes that describe symptoms and  signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider."

If your neurologist's documentation is unclear and you cannot determine whether he made a definitive diagnosis, always query him first, says Leslie Johnson, CPC, quality control auditor for Duke University Health System and owner of the billing and coding Web site AskLeslie.net. If your neurologist is not available, simply code the case using signs and symptoms as mentioned before (333.2, in this case). If neither of those is an option, it's appropriate to attempt to query the patient for signs and symptoms. "Make sure to document the contact with the date, the person spoken to, and the outcome of the conversation," Johnson says.

Bottom line: You should report a diagnosis only when your neurologist has performed a procedure and the results confirm the diagnosis. "Applying a diagnosis prematurely can have potential negative long-term effects for a patient and their insurance coverage," Hammer says.