Neurology & Pain Management Coding Alert

Signs and symptoms provide a better way

If you're using "rule out" diagnoses to justify in-office diagnostic testing, you're likely facing frequent claim denials and tainting your patients' medical records at the same time. For best results, you should always link CPT testing codes to the signs and symptoms that guide the neurologist's decision-making, coding experts say. Don't Rely on Unconfirmed Diagnoses When choosing ICD-9 codes to link to diagnostic tests such as nerve conduction studies (NCS) or imaging procedures such as magnetic resonance imaging (MRI), you should list the signs and symptoms that prompted the neurologist to suspect a particular condition rather than the suspected condition itself.
 
"For example, neurologists commonly consult with patients who exhibit the signs and symptoms of carpal tunnel syndrome," says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver. "To evaluate the patient, the physician will generally conduct NCS and possibly electromyography [EMG]. When you select diagnoses to justify the testing, you cannot rely on 354.0 [CTS] because the condition is not, in fact, known to exist." Instead, Hammer says, you should report any relevant conditions, such as joint pain (719.44, Pain in joint; hand) and enthesopathy (726.4, Enthesopathy of wrist and carpus), as well as such tell-all symptoms as numbness, dryness or "coldness" of the wrist.
 
In a second example, a patient has generalized convulsive epilepsy (345.11) that fails to respond to medication. To rule out other potential problems, such as an aneurysm (747.81) or brain tumor, the neurologist orders further testing, such as MRI or CAT (computer-assisted tomography) scan. "The physician's documentation should substantiate the diagnoses you link to the test," says Bruce H. Cohen, MD, co-director of the Brain Tumor Center at the Cleveland Clinic Foundation in Cleveland. "When the physician is assessing a patient, the term 'rule out brain tumor,' for example, is not appropriate." Therefore, you should report epilepsy (a known diagnosis) as the primary code and list any additional signs and symptoms as the secondary diagnoses. You cannot code for the medical condition that the neurologist is seeking to rule out. Use Secondary Diagnoses You should list relevant secondary diagnoses when coding for diagnostic testing. "The more information you provide, the better your justification for additional testing, if required, and the less likely the insurer is to reject the claim," Hammer says. "We usually code up to four diagnoses or symptoms if they are present."
 
For example, when coding a CAT scan for a patient with recurrent convulsions (780.39) and headaches (784.0), report 780.39 as the primary diagnosis, but also list 784.0 in case the neurologist must order additional CAT scans and MRIs. You may report family history codes (V16 to V19) as [...]