Medicare Carriers Instructed To Accept Posttest Diagnoses
Published on Thu Nov 01, 2001
Medicare carriers across the nation have long differed on whether physicians who perform diagnostic tests should use the diagnosis revealed by the test or the sign or symptom that prompted the physician to order the test in the first place. The Centers for Medicare and Medicaid Services (CMS, formerly HCFA) has ruled that the posttest diagnosis should be used.
A CMS transmittal (AB-01-144) issued on Sept. 26 states: "If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis."
The transmittal specifically cited guidelines in the ICD-9 Manual and in Coding Clinic, an authoritative facility coding guide published by the American Hospital Association.
If the test is normal, otolaryngologists should use the sign or symptom that prompted the test, CMS says. The transmittal also reiterates the longstanding ICD-9 guideline that rule-out diagnoses are not permitted. Therefore, otolaryngologists should avoid using terminology that reflects uncertainty, such as "probable," "suspected," "questionable," "rule out" or "working."
Diagnostic tests for screening, however, are not permitted even if the test reveals a problem that requires further treatment. Medicare carriers will not pay for screening tests even if they show problems that need attention. Physicians are instructed to report the reason for the test (i.e., screening, V73.x-V82.x) as the primary diagnosis. The results of the test, whether negative or positive, may be recorded as additional diagnoses.
Note: Section #4317(b) of the Balanced Budget Act specifies that referring otolaryngologists are required to provide diagnostic information to laboratories or other testing entities. The information may be communicated in a written document, an e-mail or a phone call.
Determining Which Diagnosis Code Is Most Specific
The pre- or posttest diagnosis issue has long troubled coders, who are trained to code to the highest level of specificity. Some payers, such as WPS, the part B carrier in Illinois, Michigan, Minnesota and Wisconsin, have insisted that physicians link pretest signs or symptoms to their diagnostic test CPT codes even though the posttest diagnosis is typically more specific and accurate.
The CMS instructions that posttest diagnoses should be used means that coding such tests is similar to coding biopsies. When the otolaryngologist takes a biopsy and sends it to the pathology lab, the claim form (containing the linked diagnosis) should not be sent until the lab has issued its report and the state of the sample is known. Some offices circle a "diagnosis" choice of "WAIT" to make sure the pathology diagnosis is back before the claim is processed.
For example, if the otolaryngologist sees a patient [...]
