Gastroenterology Coding Alert

Question: We have a long-standing question in our billing office. Acouple of years ago, Medicare and other insurance payers eliminated the "rule-out" aspect of diagnosis coding, so now the physician must specifically state a diagnosis. One of our physicians was consulted to see a patient with a left hip prosthesis; the patient had fallen and had hip pain. Infectious Disease saw the patient: he was found to have an infected left hip socket. This raised the question of a possible sinus tract from the left hip to the pelvis. 

The only reason our physician was asked to see the patient was to rule out fistulous communication between the left hip and the gastrointestinal tract. However, the symptoms were outside the gastro realm. This patient had no history of gastrointestinal-related problems, constipation, diarrhea, rectal bleeding, or diverticulitis. After the consultation, our physician wrote, "There is nothing to suggest abdominal or pelvic abscess," so he did not have a positive diagnosis. Our regional Medicare office once told me the physician should code the original diagnosis that prompted the visit when the physician's findings don't support the suspected diagnosis.                                                                                Colorado Subscriber



   Answer: ACMS Program Memorandum, B-01-61, effective Jan. 1, 2002, states the coding policy for outpatient diagnostic tests. It specifies that diagnoses must be reported for these tests, whereas formerly, providers needed to report only the reason that the outpatient diagnostic was ordered, regardless of the test findings or results. Specifically, it states that you cannot code narrative diagnoses for which the given diagnosis is "rule-out, probable, or suspected."

The memorandum explains how to determine the appropriate primary ICD-9-CM diagnosis code for ordered diagnostic tests. Specifically:      If a physician has confirmed a diagnosis based on results of the diagnostic test, then the physician interpreting the test should code that diagnosis. Signs or symptoms that necessitated the test can be reported as additional diagnoses if they are not explained or related to the confirmed diagnosis.      If the results of the diagnostic test are normal or do not provide a specific diagnosis, the interpreting physician should code the signs or symptoms that prompted the treating physician to order the test. And most important, in this particular case:      If the results of the diagnostic test are normal and the referring physician has recorded a diagnosis that indicates uncertainty, such as "probable," "suspected" or "rule-out," the interpreting physician should not code the referring diagnosis. In this case, the interpreting physician should report the sign or symptom that prompted the test. Diagnoses that are uncertain or unconfirmed should not be reported. 

Your referring physician's diagnosis indicated uncertainty because he wanted to rule out fistulous communication between the left hip and the gastrointestinal tract. You need to [...]