ED Coding and Reimbursement Alert

Signs and symptoms codes can help classify a visit when no distinct diagnosis can be made, and they may boost reimbursement by increasing the level of decision-making for E/M visits.

ICD-9 codes should be used to describe a diagnosis, symptom, complaint, condition or problem that caused the patient to seek/require medical care. Although claims adjusters are trained to look for a specific diagnosis, a patient visiting the ED often has a complaint that cannot be diagnosed right away. When no specific diagnosis is available to the emergency physician, the ICD-9 signs and symptoms codes should be used to provide medical necessity for a procedure or service, says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City.

Sometimes, a definitive diagnosis cannot be reached before lab or other diagnostic tests are returned, so the physician can only record an ICD-9 code of 786.09 (Respiratory distress) or even 518.81 (Acute respiratory failure), for example, even if he or she suspects 493.1x (Intrinsic asthma).

In other cases, test results are normal and a final diagnosis still cannot be determined. For example, a non-pregnant patient presents to the ED complaining of abdominal pain. The physician completes a pelvic, urinalysis, and an ultrasound, but does not find any abnormalities to explain the pain. The patient's pain subsides, but the reason she originally presented to the ED was for left lower quadrant abdominal pain (789.04).

In the absence of a specific diagnosis, ED coders should feel comfortable using diagnosis codes listed in the "Symptoms, Signs, and Ill-Defined Conditions" section of the ICD-9 code book to prove medical necessity for the visit. In the above case, 789.0x (Abdominal pain [the fifth digit is required to identify location of pain]) could be assigned to the claim.

However, some of the codes in the genitourinary chapter of the ICD-9 book also refer to symptoms rather than definitive diagnoses. For example, category 625 includes codes for pain and other symptoms associated with female genital organs. Code 625.9 (Unspecified symptom associated with female genital organs), therefore, may be used if the pain is thought to be pelvic rather than abdominal.

Some facility-based coders may be wary of using the signs and symptoms codes because of prior training as medical records coders, where rule-out diagnoses are allowed and signs and symptoms codes are not used as regularly. This latter practice is the norm for hospitals that are paid based on the most severe diagnosis for which the patient receives care during his or her stay  but it does not apply to outpatient coding because physician coders in the ED are not allowed to use suspected or rule-out diagnoses; they have to use the signs or symptoms that brought the patient to the ED.

The ED physician will normally include a statement in the medical record via a chief complaint or in the history of present illness as to why the patient is coming in. When the reason for the visit is indicated by a symptom or list of symptoms, these can be reported to justify the medical necessity of the visit. However, the medical record for the encounter must match the signs and symptoms code used when billing for the E/M visit. In other words, you cannot assign signs and symptoms retroactively; you must use the signs and symptoms documented in the patient's medical record.

Coders may gather information from anywhere in the chart, although the CPT documentation guidelines say that the only thing you can take from a nurse's or resident's documentation is review of systems (ROS); past, family and social history (PFSH); and vital signs, Thomas says.

Documentation should also identify secondary diagnoses, when applicable. Secondary diagnoses are diseases and conditions that coexist during an encounter and affect the management of the patient's care, says Wanda D. Brown, CPC, education specialist for University of Florida Jacksonville Physicians Inc. These diagnoses should be sequenced after the primary diagnosis.

"For example," Brown says, "a diabetic patient is seen for abdominal mass. The provider can code the diabetes as a secondary diagnosis, even if he is not managing the diabetes, because this systemic condition will be a factor in his medical decision-making and when prescribing medication."

The signs or symptoms codes may also justify higher levels of E/M services, since the medical decision-making portion of the E/M service is often boosted when the physician has only a sign or symptom to work with because the complaint is undefined.

Often, you can cite medical decision-making of moderate or high complexity when using signs and symptoms codes because the nature of the presenting problem may be severe and high-risk even when the final diagnosis is more benign. An example would be a patient with a terrible headache who has labs and a head CT performed, and is ultimately diagnosed with sinusitis (461.9). You should code the headache (784.0) first as the presenting problem of greater severity and the sinusitis second, says Michael Granovsky, MD, CPC, chief financial officer of Greater Washington Emergency Physicians in suburban Maryland.

Don't forget to address comorbidities that increase the complexity of the medical decision-making. Thomas offers the example of a pregnant patient in the ED. The emergency physician has to consider the pregnancy when making a treatment decision. If the decision pertains to whether or not to take x-rays for severe back pain, list the pregnancy code (648.7x, Pregnancy complicated by injury) on the claim to show the increased complexity of the medical decision-making.

The other two components of medical decision-making - risk of mortality and morbidity to the patient, and tests ordered and reviewed - are also likely to be higher when there is not a specific diagnosis. After all, a specific diagnosis is less likely to call for many tests than a sign or symptom because the cause of the symptom is unknown and needs to be discovered.