Gastroenterology Coding Alert

If you want to start 2008 right, adhere to this rule: In the absence of a definitive diagnosis, always report signs and symptoms to support medical necessity for services your gastroenterologist provides.

These steps make perfecting your ICD-9 coding as easy as 1-2-3.

If the gastroenterologist confirms a diagnosis, you should report that diagnosis instead of the signs or symptoms that prompted the procedure, according to CMS program memorandum AB-01-144.

Example: The gastroenterologist conducts colonoscopy (such as 45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) and confirms a diagnosis of Crohn's disease.

In this case, you should report 555.9 (Crohn's disease) as the primary diagnosis for the colonoscopy, but don't forget to list the signs and symptoms as secondary diagnoses.

Step one is to "see if the physician has given the patient a definitive diagnosis," says Denae M. Merrill, CPC, coder for Covenant MSO in Saginaw, Mich. "If there is no definitive diagnosis given, look for any signs or symptoms."

Example 1: During an initial consult with a new patient, the gastroenterologist suspects a diagnosis of Crohn's disease (555.9). Should you report the patient has Crohn's disease?

Watch for: Keep an eye out for any of the following phrases in your provider's documentation: "probable," "suspected," "likely," "questionable," "possible," and "still to be determined." These indicate that the provider has not formally diagnosed the patient with the condition or disease. Until testing or diagnostic services confirm that diagnosis, you should rely on signs and symptoms instead to justify medical necessity for any services the physician provides.

Here's why: If you reported only a suspected condition or disease, this would label the patient with an unconfirmed diagnosis, possibly affecting his future medical treatment. Reporting signs and symptoms when testing cannot establish a definitive diagnosis still allow physician reimbursement.

Returning to the above case, you shouldn't claim a diagnosis of 555.9 in the hopes of receiving payment if the gastroenterologist has not or cannot definitively establish a Crohn's disease diagnosis. Rather, the gastroenterologist's documentation should be strong enough to support the claim with the signs-and-symptoms diagnoses alone, regardless of the outcome of diagnostic testing.

Typical signs and symptoms indicative of Crohn's disease include abdominal pain or cramping (789.0x), diarrhea (787.91), fever (780.6), nausea (787.02) and blood in stool (578.1).

Example 2: Suppose the gastroenterologist conducts colonoscopy, but the results are inconclusive or negative for Crohn's disease. What should you do?

In this case, you should rely only on the signs and symptoms to establish medical necessity for services the GI provides, says Suzan Hvizdash, BSJ, CPC, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh.

Don't forget: In some cases, you will report signs and symptoms as secondary diagnoses, even if the physician has assigned a definitive diagnosis for the encounter.

Based on CMS transmittal AB-01-144, you may report "signs and/or symptoms ... as additional diagnoses if they are not fully explained or related to the confirmed diagnosis."

Likewise, you may report signs and symptoms that are not related to the primary diagnosis but affect medical decision-making or otherwise figure in patient treatment.

The ICD-9 (Section I. B. 8) guidelines also support this CMS directive, stating, "Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present."

In other words: If the definitive diagnosis doesn't present a complete picture of the patient's condition, you may include signs and symptoms codes in addition to the definitive diagnosis to support the physician's claim.

If the definitive diagnosis fully explains or supports the patient service, however, you should not report signs and symptoms in addition to the definitive diagnosis, confirms the ICD-9 guidelines, Section I. B. 7.