Gastroenterology Coding Alert

Watch out for these phrases in your physician's documentation

Your first line of ICD-9 coding is to attach signs or symptoms to your claim, but even after your gastro-enterologist performs a diagnostic test, you will only sometimes report a definitive diagnosis.

Strategy: By answereing four important questions, you'll avoid applying a definitive diagnosis prematurely -- which can have long-standing 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," says Susan Pryzeski, practice manager for Specialists in Gastroenterology in Elgin, Ill.

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.

ICD-9 guidelines stipulate that you should apply signs-and-symptems diagnoses if::
 • 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.

Gastro highlights: Some signs and symptoms you might see in a gastroenterologist's documentation include: abdominal pain (789.01��"789.09); appetite loss (783.0); fluid in the abdominal cavity, or ascites (789.5); unspecified chest pain (786.50); diarrhea, not otherwise specified (787.91); dysphagia (787.2); flatulence (787.3); heartburn (787.1); incontinence, feces (787.6); nausea alone (787.02), and; nausea with vomiting (787.01).

Example: During an initial consult with a new patient, a gastroenterologist suspects a diagnosis of Crohn's disease (555.9). How should you report this?

Answer: Until testing or diagnostic services confirm the Chron'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 (789.0X, Abdominal pain), diarrhea (787.91), fever (780.6), loss of appetite (783.0, Anorexia) and rectal bleeding (579.3, Hemorrhage of rectum and anus).

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 its definitive," says Doris Ward, CPC, coder/biller at KY Surgery Center in Lexington.

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 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. Facilities may use rule outs, but the regular physician medical practice should not.

"Rule out codes were themselves 'ruled out' several years ago," Pryzeski says.

ICD-9 coding guidelines (Section I B.6. and Section IV. E.) state, "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."

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 (151.X) hoping you'll be paid if the gastro-enterologist 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" (578.1) and "abdominal pain" (789.0X), 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, change request 1744 (Sept 26, 2001).

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-9 guidelines (Section I.B.8) state, "Additional signs and symptoms that may 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-9 guidelines state.