Internal Medicine Coding Alert

Question: I just got an EOB where the physician evaluated a patient with upper respiratory symptoms and chest pain. The doctor thought the patient possibly had pneumonia, so she took a chest x-ray, but it was negative. She coded and treated as a upper respiratory infection (URI). Medicare paid the office visit but denied the chest x-ray as medically unnecessary. If she had coded pneumonia, Medicare probably would have paid the chest x-ray, but the patient did not have pneumonia. Should she have coded the pneumonia? Should I have used a V code for screening for pneumonia?

Arizona Subscriber

Answer: No, you should never report an ICD-9 diagnosis code for a condition that the patient does not have. To do so is fraudulent. In September 2001, CMS issued a memorandum addressing coding of diagnostic tests. If a chest x-ray or other diagnostic test confirms a diagnosis, the physician should code the confirmed diagnosis, not the signs and symptoms that prompted the ordering of the test. If, as in your case, the diagnostic test results are normal, the signs and symptoms that prompted the ordering of the test should be coded.

A check of Arizona's local medical review policies at www.lmrp.net/lmrp/carrier/8/00821/chestx-ray.htm shows that your carrier will pay for a chest x-ray for any of the respiratory or chest symptoms indicated by diagnosis codes 786.00-786.9. Therefore, you should have coded the chest pain 786.50 (Chest pain, unspecified) or any of the patient's other respiratory symptoms and the claim would have been paid. A V code for screening would also be inappropriate here because screening tests are performed in the absence of signs or symptoms. A woman's annual mammogram or Pap smear are examples of screening tests. The patient does not have any signs or symptoms, but the test is ordered to screen for any potential disease. In your case, the patient had signs and symptoms that prompted the physician to order the test.

If you would like to read the CMS memorandum on coding for diagnostic tests, go to http://www.hcfa.gov/pubforms/transmit/AB01144.pdf.