This is
the second in a monthly series of coding-specific articles for
U.S.-based radiology practitioners that appear each month on
AuntMinnie.com courtesy of Coding Strategies Incorporated. If
you'd like to offer your comments about the material, please
e-mail editorial@auntminnie.com.
By: Melody W. Mulaik
Coding Strategies
Incorporated
Many regulatory changes for radiology were released this year.
Arguably the release with the greatest operational impact is the
Centers for Medicare and Medicaid Services (CMS) Transmittal
AB-01-144 (Change Request 1724) released on September 26, 2001.
This memorandum, effective January 1, 2002, provided
clarification regarding International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis coding
guidelines for reporting diagnostic tests for outpatient
facilities and physician offices.
At the present time, approximately
one-half of Medicare carriers across the country require the
coding submission of the patient’s signs and symptoms,
while the other half have followed
The Official ICD-9-CM Coding Guidelines for Physician and
Outpatient Services, published by the American Hospital
Association (AHA), which require the coding of the test
results.
If your practice is operating in a state
that required signs and symptoms, you must be prepared to begin
coding from the definitive diagnosis January 1, 2002. Coding from
signs and symptoms is generally easier and faster than coding
from definitive diagnoses, so expect your coders’
production to decrease slightly with these new guidelines. Also,
many coders who usually code from signs and symptoms may not be
as familiar with all of the diagnosis coding guidelines and will
benefit from additional training to ensure correct code
assignment.
The determination for payment is most
often driven by the diagnosis code assignment that indicates the
medical necessity of the ordered exam. Medicare carriers develop
Local Medical Review Policies that define the diagnoses and
conditions that they deem as medical necessities, and thus which
ICD-9 codes should result in payment. (A complete listing of
policies can be found at the Local Medical Review Policies Web site.)
When assigning diagnosis codes for
outpatient facility and physician services, it is important to
remember that documentation must be present in the
radiology report for all coded conditions. The majority of
radiology audits reveal far greater diagnosis coding errors than
procedure coding problems. Rule-out, probable, suspected,
questionable, working, and consistent with conditions may not be
coded as actual conditions.
Once a diagnosis code has been submitted
for payment, the payor views the information as a clinical
diagnosis from the physician, and that information will remain on
the patient’s record for life. No matter what role the
physician has in the coding process, they are responsible for the
accuracy of the information submitted on the claim form.
Change Request 1724 provides the following
ICD-9-CM diagnosis coding guidance:
A.
Determining the
appropriate primary ICD-9-CM diagnosis code for diagnostic tests
ordered due to signs and/or symptoms
- 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.
Example: A patient is
referred to a radiologist for an abdominal CT scan with a
diagnosis of abdominal pain. The CT scan reveals the presence of
an abscess. The radiologist should report a diagnosis of
“intra-abdominal abscess.”
Example: A patient is
referred to a radiologist for a chest x-ray with a diagnosis of
“cough.” The chest x-ray reveals a 3-cm peripheral
pulmonary nodule. The radiologist should report a diagnosis of
“pulmonary nodule” and may sequence
“cough” as an additional diagnosis.
- 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.
Example: A patient is
referred to a radiologist for spine x-ray due to complaints of
“back pain.” The radiologist performs the x-ray, and
the results are normal. The radiologist should report a diagnosis
of “back pain” since this was the reason for
performing the spine x-ray.
- If the results of the
diagnostic test are normal or nondiagnostic, and the referring
physician records a diagnosis preceded by words that indicate
uncertainty (e.g., probably, suspected, questionable, rule out,
or working), then the interpreting physician should not code the
referring diagnosis. Rather, the interpreting physician should
report the sign(s) or symptom(s) that prompted the study.
Diagnoses labeled as uncertain are considered by the ICD-9-CM
Coding Guidelines as unconfirmed and should not be reported. This
is consistent with the requirement to code the diagnosis to the
highest degree of certainty.
Example: A patient is
referred to a radiologist for a chest x-ray with a diagnosis of
“rule out pneumonia.” The radiologist performs a
chest x-ray and the results are normal. The radiologist should
report the sign(s) or symptom(s) that prompted the test (e.g.
cough).
B. Instruction to determine the reason for the test
As specified in §4317(b) of
the Balanced Budget Act (
BBA),
referring physicians are required to provide diagnostic
information to the testing entity at the time the test is
ordered. As further indicated in 42
CFR
410.32, all diagnostic tests “must be
ordered by the physician who is treating the
beneficiary.”
As defined in §15021 of the
Medicare Carrier Manual (MCM), an “order” is a
communication from the treating physician/practitioner requesting
that a diagnostic test be performed for a beneficiary. An order
may include the following forms of communication:
- A written document signed by the treating physician, which is
hand-delivered, mailed, or faxed to the testing facility
- A telephone call by the treating physician or his/her office to the testing
facility; and
- An electronic mail by the treating physician or his/her office to
the testing facility
Note: If
the order is communicated via telephone, both the treating
physician or his/her office, and the testing facility must
document the telephone call in their respective copies of the
beneficiary’s medical records.
On the rare
occasion when the interpreting physician does not have diagnostic
information as to the reason for the test and the referring
physician is unavailable to provide such information, it is
appropriate to obtain the information directly from the patient
or the patient’s medical record if it is available.
However, an attempt should be made to confirm any information
obtained from the patient by contacting the referring
physician.
C. Incidental
findings
Incidental
findings should never be listed as primary diagnosis. If
reported, incidental findings may be reported as secondary
diagnoses by the physician interpreting the diagnostic test.
D. Unrelated/co-existing conditions/diagnoses
Unrelated and
co-existing conditions/diagnoses may be reported as additional
diagnoses by the physician interpreting the diagnostic test.
E. Diagnostic
tests ordered in the absence of signs and/or symptoms (e.g.
screening tests)
When a
diagnostic test is ordered in the absence of signs/symptoms or
other evidence of illness or injury, the physician interpreting
the diagnostic test should report the reason for the test (e.g.
screening) as the primary ICD-9-CM diagnosis code. The results of
the test, if reported, may be recorded as additional
diagnoses.
F. Use of
ICD-9-CM to the greatest degree of accuracy and
completeness
Note: This
section explains certain coding guidelines that address diagnoses
coding. These guidelines are longstanding coding guidelines that
have been part of the
Official ICD-9-CM Guidelines for Coding and
Reporting.
The interpreting
physician should code the ICD-9-CM code that provides the highest
degree of accuracy and completeness for the diagnosis resulting
from the test, or for the sign(s)/symptom(s) that prompted the
ordering of the test.
In the past,
there has been some confusion about the meaning of “highest
degree of specificity,” and in “reporting the correct
number of digits.” In the context of ICD-9-CM coding, the
“highest degree of specificity” refers to assigning
the most precise ICD-9-CM code that most fully explains the
narrative description of the symptom or diagnosis.
For the latest
ICD-9-CM coding guidelines, please refer to the following Web
site:
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm#guide.
In summary, the CMS memorandum states that
effective January 1, 2002:
- All
diagnostic tests should be coded with definitive findings (if
applicable) and then signs and/or symptoms (if necessary)
- Information
can be obtained from the patient if the referring physician is
unavailable (but any information should be verified)
- Incidental
findings should only be coded as secondary diagnoses and never
primary
- Unrelated
and co-existing conditions may be reported as additional
diagnoses
- A screening
exam is always a screening exam and all findings should be
reported as secondary diagnoses
- The
Official ICD-9-CM Guidelines for Coding and Reporting
should be followed
If these new guidelines represent a change
to your coding practices and operations, you need to get prepared
immediately. Ensure your coders are adequately trained and ready
to accurately assign definitive codes. Also, contact your local
payor and ensure its local medical review policies have been
updated to reflect appropriate definitive diagnoses, otherwise
you may find numerous rejections and denials from your local
carrier until its systems are updated appropriately.
Coding definitive diagnoses for outpatient
and physician services has been the longstanding guideline
published by the AHA. The majority of non-Medicare payors already
follow these guidelines. If you have any questions regarding what
your private payors require, obtain written guidance from each
organization to ensure compliance with their guidelines.
By Melody Mulaik
AuntMinnie.com contributing writer
December 18, 2001
Melody Mulaik is president of Coding Strategies Incorporated. Her company will be presenting its comprehensive radiology-only workshop networking (CROWN) seminar series February 18 - 22 in Dallas. The company can be contacted at 877-626-3464 for further information.
Related Reading
Order compliance equals payment for outpatient radiologists,
November 19, 2001
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© 2001 Coding Strategies
Incorporated