Part B Insider (Multispecialty) Coding Alert

Published on Sun Nov 26, 2006 PDF

Know the difference between covered and non-covered symptoms

Sometimes your doctor orders diagnostic tests without knowing the patient's exact diagnosis--after all, that's what diagnostic tests are for. But many payors and carriers won't reimburse you for costs associated with diagnostic tests for vague symptoms. Here's what to do.

The challenge: You're technically not supposed to bill for the diagnosis that the laboratory gives you after the test comes back because you're supposed to bill the diagnosis that justified the test originally, explains consultant Maxine Lewis with Medical Coding Reimbursement Management in Cincinnati. But many practices do bill for the diagnosis the laboratory provides because that's more likely to get paid.

The answer: Code the symptoms that the patient's having, advises Linda Parks, an independent coding consultant in Marietta, GA. If you code them completely and carefully, you should get paid.

Be careful: Some symptoms may be covered, but others may not, Parks adds. For example, Medicare will cover a chest X-ray for shortness of breath, but not for abdomen pain. "You can't make up a symptom," Parks cautions. But if a patient really has both shortness of breath and abdomen pain, you should list shortness of breath as the primary diagnosis.

Find out more: For Medicare, you can check your carrier's Local Coverage Determination (LCD) to find out which symptoms and diagnoses are covered for each diagnostic test, notes Lewis. Ask your laboratory for a list of covered symptoms for tests it provides. Some laboratories may send you a booklet listing which diagnoses each payor covers for a particular test.

Another tip: Make the patient sign an Advanced Beneficiary Notification (ABN) for the test, advises Parks. Explain that Medicare may not pay for the test, and the patient may be financially liable if the claim is denied.

Appeal: If your payor does deny claims for collecting samples or interpreting results, you should appeal and try to figure out your insurer's guidelines for tests, says Lewis. With non-Medicare carriers, you may need to use "trial and error" to figure out which symptoms are acceptable to cover a test because the payors play their cards close to their chests.