General Surgery Coding Alert

Question: The surgeon saw a pediatric patient in the ED with a very high fever and suspected that the girl had sepsis. Should we report the diagnosis code for sepsis or for the signs and symptoms she had?

New York Subscriber

Answer: Correct coding in this instance depends on available documentation. If the surgeon stated that the diagnosis was sepsis, report the relevant code (e.g., 038.8, Septicemia; other specified septicemias). If the physician stated that he was attempting to "rule out" sepsis, however, you should report the signs and symptoms (for example, 780.6, General symptoms; fever).
 
Coders will often see notes indicating that the physician ordered tests to "rule out" or "confirm" a probable diagnosis. These terms - and similar language such as "suspected" and "questionable" - do not support the medical necessity of outpatient services (although they are acceptable when billing for hospital inpatients). CMS outpatient services guidelines explicitly state that practices should not use the condition being ruled out as the diagnoses. Instead, you should "code the condition(s) to the highest degree of certainty for that encounter/visit such as symptoms, signs, abnormal test results ..."
 
For instance, if the physician orders a chest x-ray (e.g., 71020, Radiologic examination, chest, two views, frontal and lateral) to rule out tuberculosis (TB) in an individual who had been in contact with a TB patient, you may assign any documented signs and symptoms, such as 786.2 (Cough) and V01.1 (Contact with or exposure to communicable diseases; tuberculosis). However, you should not use 011.x (Pulmonary tuberculosis) because the diagnosis is as yet unproven.