Getting paid for diagnostic studies often depends upon proper ICD-9 coding . Easy as that sounds, experienced
radiology coders will tell you diagnosis coding is anything but simple. It requires an understanding of national Medicare policy, as well as local carrier and third-party payer guidelines. Plus, it necessitates dialog between coders and radiologists coders must educate physicians about payers requirements, and physicians should provide coders with the clinical specificity they need to optimize reimbursement.
Diagnosis coding has always been challenging, admits Thomas Kent, CMM, principal of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, Md. But we are all expecting it to come under even closer scrutiny in upcoming years. Payers will be even more exacting than they have in the past.
Three main problem areas cause the most confusion, Kent says. If coders can master these, they will find claims are processed more smoothly.
Problem #1: Rule out or Probable Diagnoses
Often, radiology coders will see physician orders noting that a study is being done to rule out or confirm a probable diagnosis. These terms and similar language like "suspected" and "questionable" do not support the medical necessity of outpatient services (although they are acceptable when billing for hospital inpatients). HCFAs guidelines for reporting outpatient services, in fact, explicitly state that radiology practices should not use the condition being ruled out as diagnoses. Instead they should code the condition(s) to the highest degree of certainty for that encounter/visit such as symptoms, signs, abnormal test results ...
Rule out and related terms, Kent says, often cause improper coding. Coders need to find out why the study was done. If the test has been ordered to confirm or rule out an illness or condition, something prompted the physician to suspect the disease in the first place. Coders should assign the appropriate codes describing those signs and symptoms.
For instance, if a chest x-ray (71020) was conducted to rule out tuberculosis (TB) in an individual who had been in contact with a TB patient, the coder may assign 786.2 (cough) if documented and V01.1 (contact with or exposure to communicable diseases, tuberculosis) to describe the symptoms. However, the coder would not report a code from the 011series (pulmonary tuberculosis).
Problem #2: Coding Final Diagnosis vs. Symptoms
Another point of confusion for radiology coders is whether a final diagnosis can be reported instead of the signs or symptoms that prompted the service. According to Kent, guidelines differ from payer to payer. Coding guidelines as published in the Medicare Carriers Manual (MCM), for instance, specifically state that the relevant final diagnosis made by a radiologist or other physician must be reported. In fact, section B3 4010 of the MCM [...]
