CMS Clarifies When To Code Diagnostic Tests Based on the Results
Published on Tue Jan 01, 2002
CMS' recent program memorandum (transmittal AB-01-144) reminded Medicare carriers of the proper ICD-9 codes for diagnostic tests. While the memo reiterates many standard policies, it also clarifies a common confusion by telling practices when it is appropriate to code diagnostic tests based on the results. Family practice coders need to know all the specific ICD-9 guidelines for diagnostic tests or they could face denials and lose out on fair reimbursement.
"A lot of the information in the memo was a clarification of basic regulations, but it's a good reminder of proper diagnosis coding for diagnostic tests," says Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians. "Since family physicians perform a lot of diagnostic tests, hopefully they were coding this way already, but if they were making mistakes, it should help them."
The following "dos and don'ts'' will help coders avoid the most common pitfalls of coding for diagnostic tests.
1. Don't code the symptoms as primary for results with a confirmed diagnosis. "The CMS memo clarified a lot of misconceptions about coding for diagnostic tests," says Kathy Pride, CPC, CCS-P, HIM, applications specialist with QuadraMed, a national healthcare information technology and consulting firm based in San Rafael, Calif. "There was an argument in the coding world between those who thought you could never code a diagnostic test based on the test results and those who thought you could. The memo made it clear that you can and should code based on the results when there is a physician's confirmed diagnosis."
Do code the ultimate diagnosis once you get the results of the test. Use the initial symptoms that prompted you to do the test as secondary coding. For example, a patient presents with a suspicious cough, and the FP performs a chest x-ray in the office. The x-ray reveals pneumonia. In this case, report a diagnosis of pneumonia (e.g., 481, pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]) and sequence "cough" (786.2) as an additional diagnosis, Moore says.
2. Don't code for the suspected problem when the test comes back normal. When an FP finds normal results in a diagnostic test, some coders make the mistake of coding for the suspected problem. For example, a patient complains of chest pain, and the physician suspects gastroesophageal reflux disease (GERD). The physician performs an EKG that produces normal results. Some coders use 786.5x (symptoms involving respiratory system and other chest symptoms; chest pain) for the chest pain and 530.81 (other specified disorders of esophagus; esophageal reflux) for the suspected GERD, but this is incorrect. Coders can only report a definitive diagnosis, and in absence of one, they must report the signs and symptoms only.
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