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Cardiology Coding Alert

Medicare Carriers Instructed To Accept Post-Test Diagnoses

Published on Thu Nov 01, 2001

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 post-test 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 for the test should be the diagnosis. Previously, Trailblazer had stated that "the diagnosis code indicated on the claim should reflect the reason for performing a service, not the diagnosis found as a result of performing a test."
 
In November 1999, Cardiology Coding Alert published an article in which coding specialists recommended using the post-test diagnosis. After that, readers in some states noted that their local Medicare carriers had issued guidelines stating that only pretest diagnoses may be used when claiming for tests.

Need for Most Specific Diagnosis Stressed

The diagnostic-test issue affects cardiologists a lot because they perform many diagnostic tests, particularly echocardiograms and stress tests, for which payment can be greatly affected depending on whether a pre- or post-test diagnosis is required.
 
For example, a Wisconsin cardiologist sees a 74-year-old male patient who comes to the office complaining of shortness of breath (786.05). The cardiologist examines the patient and orders an echocardiogram (93307, echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; complete). The echo reveals evidence of mitral valve regurgitation (424.0). Now, the cardiologist would have to link the claim for 93307 with ICD-9 code 786.05 for shortness of breath, the symptom the patient had when arriving at the cardiologist's office.
 
The CMS transmittal finally clarifies that, effective Jan. 1, 2002, the most specific diagnosis code (mitral valve regurgitation) should be used, regardless of state or local carrier, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. Underlying this issue, as always, is being able to provide the medical necessity for the procedure. Had the echocardiogram been negative, it would be correct to associate shortness of breath with the echo claim.
 
The change may not affect reimbursement for cardiologists. In the previous example, for instance, WPS and other carriers requiring pretest diagnoses may have accepted shortness of breath as a diagnosis for the echocardiogram or may not have issued local medical review policies for echocardiograms that restrict certain diagnoses.
 
The new CMS guideline applies a basic coding principle namely, that diagnosis and procedure codes be selected to the highest level of specificity to procedure billing, thereby allowing the most appropriate diagnosis to be linked to the appropriate CPT diagnostic test code, Callaway says.
 
Note: Incidental and unrelated findings should not be reported as the primary diagnosis for the diagnostic test or service, even if the findings are more serious than the sign or symptom that prompted the test, the CMS transmittal notes.

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