Signs/Symptoms Codes Increase Pay Up and Safeguard Patients
Published on Thu Jun 01, 2000
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 [...]
