Signs & symptoms & medical necessity

[rchojnowski]

Is anyone else finding they have to code signs and symptoms, even though you have a definitive diagnosis, in order to cover medical necessity? And are you coding them from the start or waiting for the denial to code them?

 

[thomas7331]

Yes, there are cases where only the symptom will support medical necessity, for example under a Medicare LCD for testing for a suspected cardiac issue if the suspected problem has been ruled out during the encounter. A patient may come in with chest pain but if it is determined that the pain is due to reflux, for example, that definitive diagnosis might not support all of the testing that was done in which case there's no choice but to include the signs and symptoms that prompted the test in order to get payment. In the practices I've worked for, we coded these from the start since our software flagged the services to alert us that an additional diagnosis or waiver modifier would be needed in order to get the claim correctly processed.