Pathology/Lab Coding Alert

You won't get paid for truncated codes

If your lab gets a narrative diagnosis from the ordering physician, you'll have to assign the ICD-9 code to the highest degree of specificity. You can't add more information than the physician supplies -- but you can't report a truncated code either.

"In the context of ICD-9-CM coding, the highest degree of specificity refers to assigning the most precise ICD-9-CM code that most fully explains the narrative description of the symptom or diagnosis," CMS states. Make sure you use specific four- or five-digit codes instead of general three-digit codes. So-called "truncated diagnoses" have never been acceptable, says Barbara J. Cobuzzi, CPC, MBA, CHBME, president of Cash Flow Solutions Inc., a physician reimbursement consulting firm in Brick, N.J.

Even if the medical record does not clearly define a condition, you should not use an incomplete, truncated code. Instead, use a complete four- or five-digit code that indicates that the diagnosis is "unspecified," (due to lack of complete documentation) or "other," if a more specific ICD-9 is not available.

Example: If a physician orders a fecal-occult blood test (FOBT) due to "open gastrointestinal wound into cavity," you should report 863.99 (Other and unspecified gastrointestinal sites, with open wound into cavity; other), not 863.9 (Other and unspecified gastrointestinal sites, with open wound into cavity).