Cardiology Coding Alert

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 in the first place. CMS has ruled that the post-test diagnosis should be used. The CMS decision vindicates many coding specialists who argued in Cardiology Coding Alert and elsewhere that the post-test diagnosis should be used to code to the highest level of specificity.
 
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, cardiologists 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, cardiologists 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, notes Sueanne Bicknell, RHIA, CPC, CSS-P, compliance administrator at CPR-Heart Place, a group practice with 65 cardiologists in Dallas. In these cases, physicians 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 post-test diagnosis issue has long troubled cardiology coders, who are trained to code to the highest level of specificity, Bicknell says. 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 post-test diagnosis is typically 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, cardiologists 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 [...]