CODING UPDATE: CDC Offers Revisions to Official ICD-9-CM Coding and Reporting Guidelines

The long-standing controversy over how a coder should code outpatient diagnostic tests has been settled.
Since the advent of ambulatory payment classifications (APCs), providers have disagreed on whether to base the reason for the test on the sign or symptom, or on the confirmed and definitive diagnosis after interpretation. Now key guidelines are available at the Centers for Disease Control and Prevention Web site at http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm#guidelines.
The directives in these guidelines are identified by a letter that corresponds to the current guidelines listed on the Centers' Web site. Coders should pay close attention to the bold information under item L, which is where the majority of the revisions are found. Understanding and appropriately applying these guidelines will lead outpatient coders to accurate diagnosis coding.
E. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when the physician has not established (confirmed) a diagnosis. Chapter 16 of ICD-9-CM, Symptoms, Signs, and Ill-defined Conditions (codes 780.0-799.9), contain many, but not all codes for symptoms.
H. In the medical record, first list the ICD-9-CM code describing the diagnosis, condition, problem, or other reason related to the encounter/visit that is chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.
I. Do not code diagnoses documented as "probable," "suspected," "questionable," "rule-out" or "working diagnosis." Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
Note: This differs from the coding practices used by hospital medical record departments for coding the diagnosis of acute care or short-term hospital inpatients.
L. For patients receiving only diagnostic services during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit in the medical record that is chiefly responsible for the outpatient services provided.
Codes for other diagnoses (e.g., chronic conditions) may be included as additional diagnoses. For outpatient diagnostic test encounters that have been interpreted by a physician and when 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.
Note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.
Let's Examine Reality
In an actual facility, outpatient coders know that documentation issues exist that make complying with the coding guidelines sometimes impossible. Additionally, the guidelines can cause confusion.
The following case scenario presented by a hospital coding department confirms that confusion. Responses have been provided to [...]

- Published on 2003-03-01