CMS Memorandum Clarifies Guidelines for Reporting Final Diagnosis
Published on Fri Feb 01, 2002
Pathology and laboratory coders have disagreed whether diagnostic tests should be reported with the final diagnosis or the signs and symptoms that prompted the test. "It has been difficult for coders to know what to do because of conflicting information in writing," says Barbara J. Cobuzzi, CPC, MBA, CHBME, president of Cash Flow Solutions Inc., a medical billing firm in Lakewood, N.J. CMS has decided that the final diagnosis should be reported if the pathologist determines the diagnosis based on the test.
"It is crucial that the ICD9 Code be assigned correctly because the diagnosis must indicate medical necessity for a procedure to be covered," Cobuzzi says. To clarify which ICD-9 code should be assigned when billing diagnostic test procedures, CMS issued Program Memorandum AB-01-144. These guidelines became effective Jan. 1, 2002, in preparation for compliance with the Health Insurance Portability and Accountability Act (HIPAA), which requires most health plans to report diagnoses using ICD-9 by Oct. 16, 2002.
The memo clarifies the coding principle of reporting a diagnosis to the highest level of certainty, unless the ordered test was a screening test, or the findings were incidental or unrelated to the symptoms that prompted the test. In other words, the proper ICD-9 code may be based on the results of the test, not the reason for the test, in some circumstances.
Physician Must Make the Diagnosis
The results of a test can be reported as the diagnosis only if they are interpreted by a physician, according to the CMS memo. This is significant for pathology and laboratory coders because some lab procedures necessarily entail a pathologist's interpretation, while others do not.
"The biller may get a charge ticket with a description of the presenting signs and symptoms along with the test results, but he or she must know whether a physician assigned the final diagnosis before that code can be used," Cobuzzi says. "This becomes a compliance issue, and policies and procedures must be in place to ensure that the biller has that information."
Questions and answers reprinted in the CMS memo from Coding Clinic for ICD-9-CM, by the American Hospital Association, illustrate this point. The examples demonstrate that when a pathologist evaluates surgical specimens, such as a skin lesion or breast mass, it is appropriate to report the specific diagnosis resulting from the pathologist's examination. If the pathologist diagnoses fibroadenoma of a breast mass, report 217 (benign neoplasm of breast) rather than a less specific code, e.g., 611.72, lump or mass in breast.
Other examples in the CMS memo indicate that the results of lab tests [...]
