Gastroenterology Coding Alert

You can (and often should) use signs and symptoms as a primary diagnosis

Here's a coding rule to live by: In the absence of a definitive diagnosis, always report signs and symptoms to support medical necessity for services the doctor provides.

If the gastroenterologist confirms a diagnosis, however, you should report that diagnosis instead of the signs or symptoms that prompted the procedure, according to CMS program memorandum AB-01-144. But that doesn't mean you can't report signs and symptoms when necessary.

If the gastroenterologist doesn't confirm a diagnosis, you should still report the signs and symptoms, says Alice Church, CCS-P, coding and reimbursement analyst for Wolcott, Wood & Taylor Inc. and chief billing officer for the University of Illinois Hospital Physicians in Chicago.

Example: During an initial consult with a new patient, the gastroenterologist suspects a diagnosis of Crohn's disease (555.9). Until testing or diagnostic services confirm that diagnosis, however, 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 787.02 (Nausea), 789.0x (Abdominal pain) and 578.1 (Blood in stool).

Case 1: Confirmed diagnosis. 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 and list the signs and symptoms as secondary diagnoses.

Case 2: Inconclusive evidence. 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, says Suzan Hvizdash, BSJ, CPC, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh.

Stay Away From -Rule Outs-

ICD-9 coding guidelines state that you should not report -rule-out- diagnoses in the outpatient setting. This approach avoids labeling the patient with an unconfirmed diagnosis while still allowing for reimbursement for the physician, even if testing cannot establish a definitive diagnosis, Church says.

For example: 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.