Gastroenterology Coding Alert

CMS, ICD-9 say theres a time to code symptoms, a time to code findings.

Sometimes when youre going through an op note and a patients history, you find so much information you hardly know what to do with it all. How should you code when youve got both symptoms and diagnoses in the record?

You may be tempted to throw every diagnosis, sign, or symptom you can divine at the CMS 1500, in hopes that something will stick. Thats not proper coding, however.

Fortunately, CMS and ICD-9 guidelines spell out which diagnoses to use, though they wrap a pretty simple principle in bureaucratic language. Basically, if a procedure or service reveals or is necessitated by a finding, use that and not any additional signs or symptoms. If not, code the signs and symptoms that necessitated the service.

For example, if the patient comes in with nausea and vomiting, has an endoscopy and is found to have an ulcer,the nausea and vomiting should not be coded, says Tina Smith, CPC, CPC-H, CPC-I, CGCS, CHCA, with Coding Sense LLC of Craig, Colo.

She points to ICD-9 guidelines under Signs and symptoms, which states: 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.

The Centers for Medicare & Medicaid Services have a similar policy.

Incidental findings should never be listed as primary diagnoses. If reported, incidental findings may be reported as secondary diagnoses by the physician interpreting the diagnostic test, according to Transmittal AB-01-144 from Sept. 26, 2001.

Marion Salwin, CPC, CPC-I, cites ICD-9 Official  Guidelines for Coding and Reporting, effective Oct. 1,2007, Section 1, B, 7: For outpatient encounters for diagnostic tests that have been interpreted by a physician,and the final report is available at the time of coding, code any confirmed or definitive diagnoses documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

I would only code the findings based upon the coding guidelines, Salwin says.

When to Rely on Signs and Symptoms

ICD-9 guidelines say you should apply signs-and-symptoms diagnoses if:

" your physician cannot make a more specific diagnosis, even after he has investigated all the facts bearing on the case;

" signs or symptoms existed at the time of the initial encounter that proved to be transient and whose causes could not be determined;

" the doctor made provisional diagnoses in a patient who failed to return for further investigation or care;

" the case was referred elsewhere for investigation or treatment before the physician could make a diagnosis;

" a more precise diagnosis was not available for any other reason; or

" the patient has certain symptoms that represent important problems in medical care and that the physician wishes to classify in addition to a known cause.

E/M service: You might use the signs and symptoms to back up a significant, separately identifiable E/M service. Heres an example:

A physician sees an established patient who reports constipation and blood in stool. After performing a levelthree E/M, the physician decides to perform a flexible sigmoidoscopy. He then discovers a colon polyp, which he removes with hot forceps.

In this case, youd code 99213-25 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity) for the E/M. Modifier 25 indicates a significantly, separately identifiable E/M service from the procedure; in this case, the physician used the E/M to decide to perform a colonoscopy. Then youd code 45333 (Sigmoidoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) for the procedure.

If your doctor does not list a billable diagnosis in the op note, look for symptoms in the patient history that can be billed.

Gastro highlights: Some signs and symptoms you may see in a gastroenterologists documentation include: abdominal pain (789.01-789.09); appetite loss (783.0); fluid in the abdominal cavity, or ascites (789.51-789.59); unspecified chest pain (786.50); diarrhea, not otherwise specified (787.91); dysphagia (787.20-787.29); flatulence (787.3); heartburn (787.1); incontinence, feces (787.6); nausea alone (787.02); and nausea with vomiting (787.01).