ED Coding and Reimbursement Alert

When reporting each is appropriate

You've heard the story both ways: Some coders say reporting signs and symptoms in addition to a primary diagnosis is perfectly legitimate, while others think the definitive diagnosis should be the only word. Answer your tough diagnosis questions with these expert opinions. Add Details to Your Story Many coders believe that if your physician issues a final diagnosis, you should not report the associated signs and symptoms, because they think you're asking for extra reimbursement. But others disagree. "Signs and symptoms are appropriate to use, even if a definitive diagnosis is stated," says Robert La Fleur, MD, FACEP, president of Medical Management Specialists in Grand Rapids, Mich. "Use whatever is available in the record to indicate why the patient came to an emergency department (ED)."  

For example, a 45-year-old man presents to the ED with a complaint of severe chest pain. The physician performs a history, review of systems, physical examination, and relevant tests, including an electrocardiogram and chest x-ray. After the tests and exam, the doctor reports indigestion as the final diagnosis.

Since the initial reason the patient visited the ED was chest pain, you should report this as the primary diagnosis. CMS program memorandum AB-01-44 supports this approach, given that some payers have software that won't look beyond the first diagnosis or won't apply the second diagnosis to all the services your physician provided. Don't Leave Room for Doubt If you fail to report signs and symptoms in addition to the primary diagnosis, you may run into problems with payers, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Evanston, Ill. "The final diagnosis may not describe the reason for the encounter," she says. "Classic examples are chest pain that ends up being just indigestion, or severe abdominal pain that ends up being constipation."

The ED is unique in that the necessity for seeking service there is different than it is in other places, Gilhooly says. "The ICD-9 coding rules are very clear that the primary code that should be reported is the code that reflects the reason for the encounter." The reason a patient presents to the ED, rather than to a primary-care physician or a specialist's office, is her initial complaint (such as abdominal pain), regardless of what the physician determined as the cause of that pain, Gilhooly says.

This distinction makes painting an accurate -- and complete -- picture all the more important on your claims. Look at the Big Picture One helpful rule is to consider your decisions from the insurance company's point of view. In the example in which the chest-pain complaint is only indigestion, for instance, many insurers' standards won't deem indigestion a reasonable purpose for seeking ED [...]