News Brief: Medicare Carriers Instructed To Accept Posttest Diagnoses

Medicare carriers across the nation continue to debate whether physicians who perform diagnostic tests should use the diagnosis revealed by the tests or the sign or symptom that prompted the physician to order the tests. CMS has ruled that the posttest diagnosis should be used.
 
CMS transmittal AB-01-144, issued on Sept. 26, states: "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."
 
The transmittal specifically cites guidelines in the ICD-9 manual and in Coding Clinic for ICD-9-CM, an authoritative facility coding guide published by the American Hospital Association. If the test is normal, allergists should use the sign or symptom that prompted the test, CMS notes. The transmittal also reiterates the long-standing ICD-9 guideline that rule-out diagnoses are not permitted. Therefore, allergists should avoid using terminology that reflects uncertainty, such as "probable," "suspected," "questionable," "rule-out" or "evaluate for."
 
Diagnostic tests for screening are still not permitted, even if the test reveals a problem that requires further treatment. For screenings, allergists are instructed to report the reason for the test (i.e., screening, V73.x-V82.x) as the primary diagnosis. The results of the test, whether negative or positive, may be recorded as additional diagnoses.
 
The pre- or posttest diagnosis issue has long troubled allergy coders, who are trained to code to the highest level of specificity. Some payers, such as WPS, the Part B carrier in Illinois, Michigan, Minnesota and Wisconsin, have insisted that physicians link a pretest sign or symptom to their diagnostic test CPT codes, even though the posttest diagnosis typically is more specific and accurate.
 
In a "clarification on documentation for reimburse-ment of diagnostic tests" issued in December 1999, WPS reiterated its pretest diagnosis stand, while at the same time appealed to physicians to "spend just a few more moments asking an additional question or two, or perhaps extending the physical examination slightly, since that additional amount of information could very well make the test reimbursable " In other words, allergists and other physicians were asked to provide additional documentation so the pretest diagnosis might provide medical necessity for the test.
 
Other carriers appeared to find such contortions tiresome and changed their policies to accept posttest diagnoses. Trailblazer, the Part B carrier in Delaware, Maryland, Texas and the District of Columbia, issued a bulletin in early 2000 stating that when the highest level of certainty is the diagnosis (decision made by a physician), the correct ICD-9 code indicated on the claim [...]

- Published on 2001-12-01