Cardiology Coding Alert

Signs and symptom ICD-9 codes should be used to provide medical necessity for a procedure or service when there is not a more specific diagnosis available to the cardiologist. Although physicians are trained to look for a specific diagnosis, sometimes a patient may have a complaint that cannot be diagnosed right away.

In some cases, the complaint may be gone by the time the cardiologist evaluates the patient; in others, no definitive diagnosis can be ascertained before lab tests are returned.

In these situations and many others, signs and symptoms should be reported instead of suspected, or rule-out, diagnoses. This can be difficult for cardiologists, because for inpatient billing, they are instructed by hospitals to use suspected and rule-out diagnoses, and it is appropriate for the hospital to bill it as if the patient has that diagnosis. This, however, doesnt apply to physician component billing, whether inpatient or outpatient, and switching gears may be confusing for physicians.

Section 16 of the ICD-9 manual includes many such signs and symptoms codes (780-799.9), which should be used if a diagnosis is not available or until a diagnosis can be proven. Similarly, these codes should be used when a pathology report returns negative.

Physicians are not allowed to use suspected or rule-out diagnoses, says Cynthia Thompson, CPC, a coding and reimbursement specialist with Gates, Moore, an Atlanta-based consulting firm. So without a specific diagnosis, they have to use the signs and symptoms that brought the patient to the office and that prompted the physician to perform the rule-out tests.

Often, the cardiologists assessment and plan states that certain tests are being performed to rule out other conditions, Thompson says. But rule-outs should never be used to code physician services, so the only thing left for the physician to code is the sign or symptom that brought the patient to the office in the first place and that led the cardiologist to order or perform the rule-out test.

A patient also may come to the office with a complaint, but after the examination, the cardiologist finds nothing wrong. For example, the patient may be referred to a cardiologist by a primary-care physician following complaints of shortness of breath. During the examination, however, the cardiologist is unable to determine the cause.

In such a scenario, coding what was found (i.e., nothing) is inappropriate. Instead, the sign or symptom (i.e., shortness of breath, 786.05) should be coded to provide medical necessity for the exam. Of course, if, during the course of the examination, the cardiologist finds something that is more specific, then that diagnosis code should be used. But lacking a specific finding, it is correct and appropriate to bill using the symptom described by the patient as the reason [...]