General Surgery Coding Alert

ICD-9 signs and symptoms codes should be used to provide medical necessity for a procedure or service when there is not a more specific diagnosis available to the surgeon. Although physicians are trained to look for a specific diagnosis, sometimes a patient may have a complaint that cannot be diagnosed right away.

In some cases, a complaint may be gone by the time a surgeon evaluates a patient; in others, no definitive diagnosis can be ascertained before lab tests are returned. For example, a surgeon may excise a mass believing the patient has a lipoma. But until the pathology report is returned, the surgeon cannot be certain that what was removed was indeed a lipoma, so a definitive diagnosis cannot be made.

In this situation, and many others, signs and symptoms should be reported instead of suspected or rule-out diagnoses. Section 16 of the ICD-9 manual includes many such signs and symptoms codes (780-799.9). Similarly, these codes should be used when a pathology report returns negative.

Many surgeons, however, are wary of using these ICD-9 codes because of their years of residence at a hospital, where rule-out diagnoses are allowed and signs and symptoms codes are not used regularly. Such usage is the norm for hospitals that are paid based on the most severe diagnosis the patient receives during his or her stay, but it does not apply to physician coding.

Physicians are not allowed to use suspected or rule-out diagnoses, says Cynthia Thompson, CPC, a senior coding specialist with Gates Moore and Company, an Atlanta-based consulting firm. So without a specific diagnosis, they have to use the signs or symptoms that brought the patient to the office and prompted the physician to perform the rule-out tests.

A patient also may come to the office with a complaint, but after the examination, the surgeon finds nothing wrong. For example, the patient may be referred by a primary-care physician following complaints of abdominal pain. During the examination, however, the surgeon is unable even to reproduce the pain, much less determine its cause.

In such a scenario, coding what was found (i.e., nothing) is inappropriate. Instead, the sign or symptom (i.e., abdominal pain) should be coded to provide medical necessity for the exam. Of course, if, during the course of the examination, the surgeon finds something that is more specific, like an inflamed appendix (541), then that diagnosis code should be used. But lacking a specific finding, it is correct and appropriate to bill using the symptom described by the patient as the reason for the visit.

Avoid Labeling the Patient

In some situations, using signs and symptoms codes not only provides accuracy but also avoids inappropriately labeling the patient, which can have long-term consequences. For example, if a male patient sees his physician complaining of an unusual irritated lesion, the surgeon may suspect the lesion is cancerous and perform a skin biopsy either to confirm those suspicions or to rule out cancer as a possibility.

In either case, not only would it be incorrect to use malignant neoplasm of skin (239.2) as the diagnosis code to provide medical necessity for the biopsy, but it could severely impact the patients ability to receive health insurance in the future, even if the pathology report returns negative. Instead, signs and symptoms code 782.8 (changes in skin texture) might be more accurate and also does not label the patient.

Coding Chief Complaint

There usually is a reason in the history of present illness or in the chief complaint for the patients visit, Thompson says, and those symptoms justify the medical necessity of the visit. She notes, however, that the medical record of the visit must match the signs and symptoms code used when billing for the evaluation and management (E/M) service visit. Thompson adds that this should be documented as the patients chief complaint in his or her history of the present illness.

You cannot make up signs and symptoms after the fact, Thompson says. You have to use the signs and symptoms documented in the patients medical record. If the physician noted the patients complaint as epigastric pain, then use ICD-9 code 789.06 (abdominal pain, epigastric).

Note: If the visit ends with a specific diagnosis, that would replace any signs and symptoms code previously considered.

Thompson also cautions coders using signs and symptoms codes to note any specific exclusions in the ICD-9 manual. She points to the abdominal category referred to above, where right under the 789 code, the manual directs coders to exclude male and female genital organs, for which it provides other, specific codes.

In addition, she notes, abdominal pain codes (789.0x), like most signs and symptoms codes, require a fifth digit. Some practices often use 789.00 (unspecified) without noting that there are nine specific body areas, one of which likely corresponds to the patient complaint. Carriers may reject services if a nonspecific ICD-9 code is used, Thompson explains, so coders should be careful to use a specific site code, such as 789.01 (right upper quadrant).

Boost E/M Levels

The signs or symptoms codes in the ICD-9 manual not only support the need for tests, they also can justify higher levels of service, Thompson says, noting that the medical decision-making portion of the E/M services often is boosted when the physician has only a sign or symptom to work with due to the undefined nature of the complaint. Often, you can cite medical decision-making of a moderate or high complexity when using signs and symptoms codes because the situation increases the number of diagnoses/management options in the decision-making category, Thompson maintains.

The other two components of medical decision-making table of risk and tests ordered and reviewed also are likely to be higher when there is no specific diagnosis, says Kathleen Mueller, RN, CPC, CCS-P, an independent coding and reimbursement specialist in Lenzburg, Ill. When a problem is undiagnosed, it often means the doctor will have to order tests to try to determine the patients problem. After all, a specific diagnosis is less likely to call for a wide variety of tests than a sign or symptom because the cause of the symptom is unknown and needs to be discovered.

And because diagnostic procedures ordered is one of the three components of the table of risk, the level of risk may increase because the highest category on the risk table determines the entire risk component.

Examples of Signs and Symptoms ICD-9 Codes 780.6 Fever Whenever a patient develops a fever, further investigation likely is warranted. If the patient is in the hospital after a procedure with a global period, no additional evaluation and management (E/M) can be billed unless the surgeon can prove the fever is unrelated to the original procedure. For example, a patient is being treated in the hospital for diverticulitis, for which no surgery was performed. A day or two later, the patient is about to be released from the hospital when suddenly he develops a high fever. In this scenario, the fever likely would bump up the level of hospital E/M visit charged by the surgeon, says Kathleen Mueller, RN, CPC, CCS-P, an independent coding and reimbursement specialist in Lenzburg, Ill. If the patient was nearing discharge and you billed out a level-one visit, 99231 (subsequent hospital care, problem-focused interval history and exam, straightforward or low-complexity medical decision-making), the fever alone warrants a higher level visit. A level-one visit means the patient is ready for discharge and stable, Mueller notes. Level two means they have abnormal response to treatment or abnormal lab tests, and level three means they are worsening. The fever could be an indication that the patient is septic; that would turn a level-one visit into a level-three. Even if there is no sepsis, the visit would be bumped up to level two, Mueller says, adding that in these scenarios, the history likely would be strengthened to correspond to the new, advanced level of decision-making required. Of course, in all of these cases, the documentation has to support the level of service that is billed. 782.0 Disturbance of Skin Sensation This code is preliminary for the diagnosis of carpal tunnel syndrome (354.0). You do not want to give a carpal tunnel diagnosis without an EMG (electromyogram) or nerve conduction study, Mueller says. Like a cancer diagnosis, the label can gravely harm the patients ability to obtain health insurance, in particular disability and workers compensation coverage, where it will be considered a pre-existing condition, with or without the confirmatory test results. Carpal tunnel syndrome can only be proven after the studies have been performed. No diagnosis, only symptoms, can be ascertained before those studies are complete, and the symptom is 782.0, Mueller conveys. 782.8 Changes in Skin Texture A male patient comes in to see the surgeon, complaining about a lesion on his trunk that seems to be changing texture and now is scaly. The surgeon removes the lesion and sends it to pathology. A few days later, the pathology report determines the problem is a seborrheic lesion. The excision of the lesion would be coded 1140x (excision, benign lesion, except skin tags, [unless listed elsewhere] trunk, arms or legs). The confirmatory diagnosis, 702.11 (inflamed seborrheic keratosis), would be used for the excision procedure. The appropriate E/M code, however, would be billed with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), and 782.8 would be the corresponding diagnosis code for this visit. By using this sign or symptom code, the surgeon indicates that the lesion was changing (which is why it was removed) and that it was not a cosmetic procedure, Mueller says. 782.4 Jaundice, Unspecified, Not of Newborn This code often justifies a level-five E/M visit, Mueller says, because it is a life-threatening condition. Further, the surgeon must discover why the patient has jaundice in the first place, and there are several possibilities. For example, Mueller notes the patient may have a gallstone, a pancreatic or bile duct tumor, or possibly a liver disorder such as hepatomegaly (enlargement of liver). In any event, the patient will require lots of tests, including a liver panel and a liver CT scan, and the level of risk treating this patient is very high. Once the specific diagnosis that resulted in the jaundice is determined, treatment will follow, but the jaundice ICD-9 code provides medical necessity for these high-level E/M services. 799.2 Nerves Patients often are nervous when seeing their physicians, particularly before surgery. The patient occasionally can be so nervous that whatever procedure was being performed has to be discontinued. When the surgeon notes the discontinued procedure, he or she may use the term anxiety. Unfortunately, this term may be understood by the coder to mean code 300.00 (anxiety state, unspecified), which likely was not the surgeons intent because this code labels the patient as neurotic when the patient may just be nervous. ICD-9 300 is definitely overused, Mueller says. Giving the patient a psychiatric label when the patient is nervous before or during a procedure is definitely something that should be avoided. Mueller recommends that 799.2 be used instead, and she notes that nervousness, as described by 799.2, is a valid reason for discontinuation of a procedure and is an excellent secondary ICD-9 code.