Optimal Diagnosis Coding for Rule-Outs and Screening
Published on Fri Jan 01, 1999
If a pediatrician orders a test to rule out a certain condition, what kind of diagnosis code should you use? If you suspect that a problem exists, and the tests show that it does, what effect does this have on the diagnosis code? This is a recurring question, especially in pediatrics, because babies cant help with the history by telling you how they feel.
You cant code based on the lab finding or the x-ray result alone, says Patricia S. Wildman, RRA, clinical reimbursement auditor at Childrens Hospital in Boston, MA. But, if the diagnosis is not known before the test is done, you should code based on the signs and symptoms noted by the pediatrician when the test was ordered, she advises.
A screening is a screening is a screening, regardless of how it comes back, says Alison Morris, CCS, coding team leader for Georgia Physician Services (six pediatricians, more than 50 physicians altogether) of Fayetteville, GA. You should code the sign or symptom only.
Code the reason the patient is having the test, Wildman asserts. If a diagnosis is not known, then code the sign or symptom that brought the patient in for the test.
Lets say a child has a cough and a fever, and you want to rule out pneumonia. You should use the ICD-9 code for a cough (786.2) for the primary diagnosis, and the code for a fever (780.6, except in newborns, when you should use 778.4) for the secondary diagnosis code, says Morris.
Note: It is important to avoid using unconfirmed diagnosis codes because insurance companies maintain a database of all of these codes. When these patients then apply for life, health, or disability insurance, the company will look for any problems the patient had in the past. For example, dont use the diagnosis for tuberculosis (011.90) for a screening PPD; instead, use the diagnosis code for screening for tuberculosis (V74.1). Otherwise, your patient will end up with a permanent history of having had tuberculosis on his or her medical record, and this could have serious adverse effects on future insurability.
Secondary Diagnosis Codes
There are no rule-out codes, but secondary diagnosis codes can be very useful in a typical rule-out scenario. No, insurance companies dont always pay attention to the secondary diagnosis codes. If youre filing electronically, says Morris, theyll only pick up the first one. But its good to have the additional code on the claim form anyway.
In the above example, 786.2 should be the first diagnosis, but having 780.6 on the form [...]
