Gastroenterology Coding Alert

Know which key phrases to seek in your physician’s documentation.

Whether you’re new to GI coding or you’ve been reporting these services for years, you’ve certainly come upon situations when you weren’t sure whether to bill a definitive diagnosis or just the signs and symptoms.

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

Danger: If you apply 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. Plus, it could hurt the patient’s chances of getting life insurance – or could vastly elevate the cost.

What Do Signs and Symptoms Entail?

Get this straight: In the absence of a definitive diagnosis, you should report signs and symptoms to support medical necessity for services your gastroenterologist provides.

The 2019 ICD-10 guidelines stipulate that you should apply signs-and-symptoms diagnoses if:

• The physician cannot make a more specific diagnosis, even after he has investigated all the facts bearing on the case.
• The physician makes a definitive diagnosis, but the sign or symptom is not routinely associated with that condition.
• When the patient is in a coma and requires the addition of coma scale codes to the claim.
• If the patient falls repeatedly and you need to tell the insurer about the history of falls.
• When the patient has systemic inflammatory response syndrome of non-infectious origin
• To indicate the NIH stroke scale in a patient who had an acute stroke.

Gastro highlights:  Some signs and symptoms you might see in a gastroenterologist’s documentation include: abdominal pain (such as R10.11; unspecified chest pain (R07.9); diarrhea (R19.7); flatulence (R14.3); gas pain (R14.1), and abdominal distension (R14.0).

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?

Answer: 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, diarrhea, fever, loss of appetite, and rectal bleeding.

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. In other words, you should never assign a diagnosis until it is definitive.

Example: The gastroenterologist conducts a colonoscopy (such as 45378, Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed [separate procedure]) and confirms a diagnosis of Crohn’s disease. In this case, you should report K50.90 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.

Example: Once again, the gastroenterologist conducts colonoscopy, but the results are inconclusive or negative for Crohn’s disease. In this case, you should rely only on the signs and symptoms to establish medical necessity for services the GI provides.

Can I Ever Report a ‘Rule-Out’ Dx?

You should never report “rule-out” diagnoses in the outpatient setting. “Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients,” the ICD-10-CM Guidelines indicate.

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.

Example: You shouldn’t claim a diagnosis of stomach cancer hoping you’ll be paid if the gastroenterologist has not (or cannot) establish definitively a stomach cancer diagnosis, even if he notes “Rule out stomach cancer” in the medical record.

Instead, you should assign codes for other documented symptoms, such as “blood in stool” and “abdominal pain,” to describe the patient’s symptoms in the absence of a stomach cancer diagnosis.

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.

With a Definitive Dx, Are Symptoms Secondary?

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.