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Dx for tests/procedures

  1. #1
    St. Louis
    Default Dx for tests/procedures
    Medical Coding Books
    Looking for another opinion...if pt comes in to Urgent Care for possible UTI, the doc sees the pt, runs a UA and determines pt has a UTI.

    I charge the OV & UA...I was taught to code the UA with a sign/symptom not the definitive dx??? I have since been informed that I should code the definitive dx for the UA NOT the signs/symptoms???

    Any help is greatly appreciated.

  2. #2
    Columbia, MO
    you can use either but not both you may code what is known at the time of coding or the definitive after study. You cannot use the symptoms for one procedure and the definitive for a different procedure. So either is acceptable but not both.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Harrisburg PA
    Default Dx coding for test
    Based on the ICD 9 Coding Guidelines (found in the front of your ICD 9 manuals or you will find if the definitive dx is know at time of billing you should be coding the test with the definitive not Signs and Symptoms.

    Section IV.Diagnostic Coding and Reporting Guidelines for Outpatient Services

    E. Codes that describe symptoms and signs
    Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the contain many, but not all codes for symptoms.

    L. Patients receiving diagnostic services only
    For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
    For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign V72.5 and/or a code from subcategory V72.6. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the V code and the code describing the reason for the non-routine test.
    For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.
    Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.


    10 - ICD -9-CM Coding for Diagnostic Tests
    (Rev. 1, 10-01-03)
    The ICD-9-CM Coding Guidelines for Outpatient Services (hospital-based and physician office) have instructed physicians to report diagnoses based on test results. Instructions and examples for coding specialists, contractors, physicians, hospitals, and other health care providers to use in determining the use of ICD-9-CM codes for coding diagnostic test results is found in Chapter 23.

    CMS Chapter 23

    10.1.1 - Determining the Appropriate Primary ICD-9-CM Diagnosis Code for Diagnostic Tests Ordered Due to Signs and/or Symptoms
    (Rev. 1, 10-01-03)
    A. Confirmed Diagnosis Based on Results of Test
    If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that
    prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis.
    B. Signs or Symptoms
    If the diagnostic test did not provide a diagnosis or was normal, the interpreting physician should code the sign(s) or symptom(s) that prompted the treating physician to order the study.

    I hope this gives you clarity.

    Last edited by CBaer; 01-26-2012 at 06:36 AM. Reason: Additional info

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