General Surgery Coding Alert

Medicare carriers have long differed on whether physicians who perform diagnostic tests should report the diagnosis revealed by the test or the sign or symptom that prompted the test. Now CMS has ruled that the post-test diagnosis should be used.
 
A CMS transmittal (AB-01-61) issued on Sept. 26 states: "If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis."
 
If the test is normal, surgeons should use the sign or symptom that prompted the test. The transmittal also reiterates the longstanding ICD-9 guideline that rule-out diagnoses are not permitted. Therefore, surgeons should avoid using terminology that reflects uncertainty, such as "probable," "suspected," "questionable" or "rule-out."
 
Diagnostic tests for screening, however, are not permitted, even if the test reveals a problem that requires further treatment. Physicians are instructed to report the reason for the test (i.e., screening, V73.x-V82.x) as the primary diagnosis. The results of the test, whether negative or positive, may be recorded as additional diagnoses.
 
Note: Section #4317(b) of the Balanced Budget Act specifies that referring surgeons are required to provide diagnostic information to laboratories or other testing entities. The information may be communicated in a written document, an e-mail or a phone call.
 
The pre- or post-test diagnosis issue has long troubled coders, who are trained to code to the highest level of specificity. Some payers, such as WPS, the Part B carrier in Illinois, Michigan, Minnesota and Wisconsin, have insisted that physicians link pretest signs or symptoms to their diagnostic test CPT codes, even though the post-test diagnosis is typically more specific and accurate.
 
The CMS instructions that post-test diagnoses should be used means that coding such tests is similar to coding biopsies. When the surgeon takes a biopsy and sends it to the laboratory, the claim form (containing the linked diagnosis) should not be sent until the pathology lab has issued its report and the state of the sample is known. Some offices circle a "diagnosis" choice of  "WAIT" to make sure the pathology diagnosis is back before the claim is processed.
Surgeons With In-House Labs Are Most Affected
For reimbursement, the diagnostic test issue affects surgeons less than other specialists, such as radiologists and cardiologists, who perform and interpret an array of tests. However, surgery practices with in-house vascular or mammography labs that treat Medicare patients in states where pretest diagnoses were requested are likely to welcome the CMS ruling, particularly because vascular laboratories have been targeted and are now highly scrutinized, says Arlene Morrow, CPC, a general [...]