Medical Necessity Key for Biopsy, Test Reimbursement
Published on Wed Dec 01, 1999
Getting reimbursed for biopsies or diagnostic testing can be difficult because otolaryngologists may be using the wrong diagnosis codes to show medical necessity. By using the post-test diagnosis when coding the procedure, otolaryngologists can increase their chances that an insurance carrier will pay up.
Many otolaryngology coders believe they must use a pre-biopsy diagnosis or indication when they bill for the biopsy that was performed. For example, if a patient diagnosed with chronic dysphagia (787.2, dysphagia, difficulty in swallowing) is sent to the otolaryngologist for a laryngoscopy with biopsy (31535, laryngoscopy, direct, operative, with biopsy), and the biopsy confirms the patient has a tumor, the coder will attach the dysphagia diagnosis (787.2) to the laryngoscopy code, even though dysphagia does not provide medical necessity for the test. Reimbursement will be denied unless a second diagnosisfor example, an edema (478.6, edema of larynx)also is included.
The same problem also extends to diagnostic tests. For example, a family physician sends a patient diagnosed with unspecified hearing loss (389.9, deafness NOS) to the otolaryngologists office for audiologic testing. The test determines the patient has a conductive hearing loss (389.00). The most appropriate code to use would be the most specific diagnosis, rather than an undefined code, says Randa Blackwell, a coding specialist with the Department of Otolaryngology at the University of Maryland in Baltimore, but some codersand carriersinsist that the pre-test diagnosis be used.
Note: In the case of audiologic testing, unspecified hearing loss still would be a payable diagnosis, if not the most accurate one.
Some coders argue that the diagnosis that originally prompted the physician to order the biopsy should be the one attached to the charge for the procedure. They call using the diagnosis from the test results back-coding and are under the impression it is improper. However logical this may seem, it is contrary to Health Care Financing Administration (HCFA) guidelines and often will result in denied reimbursement for tests that should have been paid.
In addition, some third-party payers are insisting that physicians use the pre-test diagnosis code, says Dari Bonner, CPC, CPC-H, CCS-P, president of Xact Coding and Reimbursement in Port St. Lucie, FL. She points, however, to a proverbial mountain of guidelines from Medicare and the American Medical Association (AMA), all of which maintain that it is perfectly legitimateand usually preferableto use the results of the test as the diagnosis to accompany the charge for it.
Post-test Diagnosis More Specific
According to the October 1996 Medicare guidelines on the use of ICD-9 codes, physicians may not use rule-outs or suspected as a reason [...]
