Signs and Symptoms Increase Pay Up and Safeguard Patients
Published on Thu Jun 01, 2000
ICD-9 signs and symptoms codes should be used to provide medical necessity for a procedure or service when there is not a more specific diagnosis available to the otolaryngologist. Although physicians are trained to look for a specific diagnosis, sometimes a patient may have a complaint that cannot be diagnosed right away.
In some cases, the complaint may be gone by the time the otolaryngologist evaluates the patient; in others, no definitive diagnosis can be ascertained before lab tests are returned. For example, an otolaryngologist may excise a mass believing the patient has a lipoma; however, until the pathology report is returned, the otolaryngologist cannot be certain that what was removed was indeed a lipoma, so a definitive diagnosis cannot be made.
In this situation, and many others, signs and symptoms should be reported instead of suspected, or rule-out, diagnoses. This can be difficult for otolaryngologists, because for inpatient billing, they are instructed by hospitals to use suspected and rule-out diagnoses, and it is appropriate for the hospital to bill it as if the patient has that diagnosis. This, however, does not apply to physician component billing, whether inpatient or outpatient, and switching gears may be confusing for physicians. Section 16 of the ICD-9 book includes many such signs and symptoms codes (780-799.9), which should be used if a diagnosis is not available or until a diagnosis can be proven. Similarly, these codes should be used when a pathology report returns negative.
Physicians are not allowed to use suspected or rule-out diagnoses, says Cynthia Thompson, CPC, a coding and reimbursement specialist with Gates, Moore, an Atlanta-based consulting firm. So without a specific diagnosis, they have to use the signs or symptoms that brought the patient to the office and that prompted the physician to perform the rule-out tests.
Often, the otolaryngologists assessment and plan states that certain tests are being performed to rule out other conditions, Thompson says. But rule-outs should never be used to code physician services, so the only thing left for the physician to code is the sign or symptom.
A patient also may come to the office with a complaint, but after the examination, the otolaryngologist finds nothing wrong. For example, a primary-care physician following complaints of a headache may refer the patient to an otolaryngologist. During the examination, however, the otolaryngologist is unable to determine its cause.
In such a scenario, coding what was found (i.e., nothing) is inappropriate. Instead, the sign or symptom (i.e., headache, 784.0) should be coded to provide medical necessity for the exam. Of course, if, during the course of the examination, the otolaryngologist finds something that is more specific, then that diagnosis code should be used. But lacking a specific finding, it is correct [...]
