ICD 10 Coding Alert

Rule 1: If the diagnostic test did not provide a definitive diagnosis or came out with normal results, you should code the sign or symptom that prompted the treating physician to order the study. Say, in the previous scenario, the CT scan results came back without any abnormal findings, then you would report the symptom R10.9 instead of K65.1.

Rule 2: If the diagnostic test was normal, but the referring physician records a suspected (aka probable, suspected, questionable, rule out, or working) diagnosis, you should not code the referring diagnosis. Instead, you should report the presenting signs and symptoms. The ICD-10-CM guidelines warn, “The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.” For instance, suppose the physician’s notes indicated “suspected blockage of a bile duct by gallstones,” but the CT scan came out normal. Again, you would report the symptom (R10.9) rather than the suspected condition as the reason for the test.

Rule 3: If the patient is receiving only diagnostic services during the outpatient visit, you would list first the condition that is the main reason for the visit on the claim. This code should be your primary diagnosis. Then, code for other diagnoses (such as chronic conditions) on the following lines. For example, say a patient with chronic gastritis went for the CT scan, and test results revealed the presence of a peritoneal abscess. On your claim you should list K65.1 as your primary diagnosis and K29.40 (Chronic atrophic gastritis without bleeding) as your secondary diagnosis.

Remember: “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification,” state the 2020 ICD-10-CM Official Guidelines for Coding and Reporting (www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf). “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present,” the guidelines note.

Understand This Chronic Condition Scenario

Scenario 2: A patient already diagnosed with liver cancer visits the gastroenterologist for esophageal varices that are a direct result of the cancer. On the first line of your claim, you would list I85.00 (Esophageal varices without bleeding) for the presenting problem (varices), and then report the appropriate liver cancer code, such as C22.0 (Liver cell carcinoma).

Challenge: Should you report the chronic condition?

Do not code the chronic condition if it is unrelated to the primary reason for the visit. For instance, if the liver cancer patient in scenario 2 presented with dyspepsia, you’d code only K30 (Functional dyspepsia), and not C22.0, unless the liver cancer condition was also being considered or treated during the encounter.

Consider ‘Z’ Codes for Preop Exams

Scenario 3: A patient who is scheduled for a gall bladder surgery presents for a pre-op evaluation. The physician lists the condition prompting the surgery as acute cholecystitis (K81.0) and the underlying medical condition as diabetes (such as E11.9, Type 2 diabetes mellitus without complications).

Challenge: Should you report the screening code?

Sometimes, a physician might order a diagnostic test in the absence of signs and symptoms, or perform a preop evaluation for the patient. If the chief reason for the encounter is a preop evaluation, list first a code from category Z01.818 (Encounter for other preprocedural examination) to describe the preop evaluation. Then, assign a code for the condition prompting the surgery as an additional diagnosis (in this case, K81.0). Any condition discovered during the screening should be reported as additional diagnosis codes.

Z codes take the spotlight, too, when a patient has no signs or symptoms and the gastroenterologist performs a test solely for screening purposes. In this case, you should disregard typical diagnosis codes and locate an applicable Z code to describe the test to the payer.

Other technicalities: List the screening code first if the reason for the visit is specifically the screening exam. Report the screening code as an additional code, however, if the physician performs the screening during an office visit for other health problems. Additionally, if the screening returns an abnormal result, then code those results as an additional diagnosis.