ED Coding and Reimbursement Alert

Don't let signs and symptoms throw you for a loop

You-re never surprised when the doctor lists conditions in the chart that aren't final diagnoses, but when those conditions add crucial information about the reason for the patient's presentation, they may be critical to getting your claim paid. Use these five key concepts to determine when to include the information and when to chuck it.

1. Use Signs and Symptoms to Pinch Hit

When the physician hasn't stated a final diagnosis, you still need to explain why the patient came to the emergency department.

In such cases, reporting signs and symptoms as the reason for the encounter is appropriate, says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, Fla. -Many times you-ll see that the physician will only give us a symptom as a diagnosis because of inconclusive lab tests or radiology reports, or future testing that needs to be done,- she says.

2. Don't Shy Away From V Codes

Coders are often hesitant to report V codes, but sometimes they are the most accurate descriptors of the reason for the patient's trip to the ED. According to the ICD-9-CM Official Guidelines for Coding and Reporting (published on CMS- Web site in April 2005), codes V01.0 (Cholera) through V84.8 (Genetic susceptibility to other disease) are appropriate codes to identify diagnoses, signs, symptoms, conditions, problems, complaints, and other possible reasons for the ED encounter.

-It sounds like a simple, straightforward concept, but over the years it hasn't been clearly defined in the emergency department, and at times, we have been reluctant to report such conditions as symptoms or related conditions on ED claims,- Marsh says. -This document gives us supporting evidence that reporting symptoms is the appropriate thing to do.-

Remember that listing a V code as the primary diagnosis on the claim may cause some reimbursement issues, says Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI, an ED coding and billing company in Stoneham, Mass. When appropriate, you should place the V code in the secondary position and use a stronger sign or symptom code as the primary diagnosis, he says.

3. Separate Dx Code From Its Kin

If the ED physician has assigned a final diagnosis, don't report extra codes for signs and symptoms that are integral to that diagnosis. For instance, if the physician lists a final diagnosis of -acute asthma- (493.2x), you don't need to report -wheezing- (786.07) as well, because wheezing is a symptom of asthma.

Additional signs and symptoms that aren't related to the final diagnosis are fair game, however. For example, if the physician's final diagnosis is -lacerated finger- (883.0), but he also documents that the patient has a fever, you can report an additional code for the fever (780.6).

Reporting codes for unrelated signs and symptoms may be pivotal in determining medical necessity for certain tests, Marsh says. Suppose a patient receives a computed tomography or an electrocardiogram for chest pain (786.5x), but the physician's final diagnosis is indigestion (536.8). In this case, you-ll not only need to report the chest pain to justify medical necessity for the tests, but you-ll need to report it first on the list.

4. Be Thorough With Chart Inspection

Make sure you review the entire record when determining the specific reasons for the encounter and the conditions the physician treated, Marsh says. For example, instead of just reading what the physician wrote, go ahead and look at the radiology report to make sure the patient had an x-ray.

And as always, remember to code to the highest level of specificity. -Using the fourth or fifth digit when it is required--or just when you do have that information--is an important concept to follow,- Marsh says.

5. Look Twice for -Impending- Conditions

When you get a chart on which the ED physician denoted a diagnosis as -impending- or -threatened,- you should follow several guidelines to decide which ICD-9 code to report. First, determine whether the -threatened- condition occurred in the end. If so, go ahead and report it as the final diagnosis if the physician confirmed it.

When the condition didn't occur, use the reference index and the main term to determine whether the condition has a subterm that mentions -impending- or -threatened.- If you find such a subterm listed, you can find the most specific code. If not, refer back to the underlying condition--not the condition described as -impending- or -threatened,- Marsh says.

For example, you see -threatened abortion- (640.0x) in the patient's record. You search the record thoroughly and discover that the physician never performed the abortion. Because abortion has -threatened- as a subterm, you don't have to look through the chart for an underlying condition, such as bleeding during pregnancy.