Gastroenterology Coding Alert

Many gastroenterology claims lack definitive diagnoses — so use these codes to collect.

When your gastroenterologist performs or orders a diagnostic test, you have to submit your claim whether or not you know the definitive diagnosis — and that’s when signs and symptoms can save the day.

In black and white: “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider,” according to the ICD-10-CM Official Guidelines for Coding and Reporting.

Strategy: By answering four vital questions, you’ll avoid applying a definitive diagnosis prematurely — which can have long-standing consequences for a patient and the patient’s insurance.

Here’s why: If you report a diagnosis for colon cancer and the biopsy comes back negative for cancer, you have now given that patient a condition he or she doesn’t have, and it’s next to impossible to get that corrected with insurance companies. That’s why signs and symptoms codes are so important.

Learn the answers to these four questions so you’ll always know when to submit a sign or symptom code.

Question 1: What Do Signs and Symptoms Entail?

In the absence of a definitive diagnosis, you should report signs and symptoms to support medical necessity for services your gastroenterologist provides, in situations such as the following:

• The physician cannot make a more specific diagnosis, even after he has investigated all the facts bearing on the case.
• Signs or symptoms existing at the time of the initial encounter that proved to be transient and whose causes could not be determined.
• Provisional diagnoses in a patient who failed to return for further investigation or care.
• Cases referred elsewhere for investigation or treatment before the physician could make a diagnosis.
• Cases in which a more precise diagnosis was not available for any other reason.
• Certain symptoms that represent important problems in medical care and that the physician might wish to classify in addition to a known cause.

Gastroenterology  highlights: Some signs and symptoms you might see in a gastroenterologist’s documentation include upper abdominal pain (such as R10.10), diarrhea (R19.7), flatulence (R14.3), gas pain (R14.1), nausea (R11.0), and nausea with vomiting (R11.2).

Example:  During an initial consult with a new patient, a gastroenterologist suspects a diagnosis of Crohn’s disease (K50.90). How should you report this?

Solution:  Until testing or diagnostic services confirm the Crohn’s diagnosis, you should rely on signs and symptoms to justify medical necessity for any services the physician provides. Typical signs and symptoms indicative of Crohn’s disease include abdominal pain/cramping, diarrhea, fever, loss of appetite, and rectal bleeding, among other symptoms.

If you are reporting the symptoms rather than a definitive diagnosis, your claim will be stronger if you report everything the patient is experiencing rather than just choosing one diagnosis. “It is appropriate to code all diagnoses that co-exist at the time of the visit that affect patient treatment or management,” says Matthew Menendez, vice president of sales and marketing with White Plume Technologies. “As always, make sure documentation supports your coding.”

Question 2: Will I Always Report a Definitive Dx After a Procedure?

You should report a definitive diagnosis when your gastroenterologist has performed a procedure and the results confirm it.

Example: The gastroenterologist conducts a colonoscopy and confirms a diagnosis of Crohn’s disease with rectal bleeding. In this case, you should report K50.911 as the primary diagnosis for the colonoscopy.

However, if your gastroenterologist performs a procedure and the evidence is inconclusive, you should fall back on signs and symptoms. For instance, if, during the colonoscopy, the gastroenterologists finds results negative for Crohn’s disease, you should rely only on the signs and symptoms to establish medical necessity for services the doctor provides.

Question 3: Can I Ever Report a ‘Rule-Out’ Diagnosis?

You should never report “rule-out” diagnoses in the outpatient setting. Facilities may use rule outs, but the regular physician medical practice should not.

ICD-10 coding guidelines state, “The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.”

By taking this approach, you avoid labeling a patient with an unconfirmed diagnosis while still allowing for your gastroenterologist’s reimbursement for services rendered, even if she cannot establish a definitive diagnosis through testing.

Watch  out: The following phrases in your physician’s documentation can indicate that the physician has not formally diagnosed the patient with the condition or disease:

• Probable
• R/O or rule out
• Suspected
• Likely
• Questionable
• Possible
• Still to be determined.

Your physician’s documentation should be strong enough to support the claim with the signs and symptoms diagnoses alone, regardless of the diagnostic testing outcome.

Question 4: Should I Add Signs and Symptoms With a Definitive Dx?

Occasionally, you’ll report sign and symptoms as secondary diagnoses, even if your gastroenterologist has assigned a definitive diagnosis for a patient encounter.

When? You can report “signs and/or symptoms as additional diagnoses if they are not fully explained or related to the confirmed diagnosis,” according to CMS transmittal AB-01-144. Similarly, you may report signs and symptoms that are not related to the primary diagnosis but affect your physician’s medical decision-making or otherwise determine how he formulates a patient’s treatment.

In fact, ICD-10 guidelines state, “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.”

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

On the other hand, if your gastroenterologist’s definitive diagnosis explains or supports the service he provides for the patient, you should not report signs and symptoms in addition to the definitive diagnosis, ICD-10 guidelines state.