Medicare Compliance & Reimbursement

Look for these phrases in your physician's documentation. Typically, your first-listed ICD-9 code is your physician's primary diagnosis. However, if your doctor performs a diagnostic test but offers no confirmed diagnosis, you may need to report the patient's signs and symptoms instead. Balance these factors by confronting four frequent coding issues. Payoff: You'll avoid applying a definitive diagnosis prematurely, which can have long-standing consequences for a patient and the patient's insurance. What Are The Signs And Symptoms?
Careful: When it comes to patient testing, a diagnosis code to support the necessity of a test must represent the documented reason why the patient has been sent for the test, says Marianne Wink, RHIT, CPC, ACS-EM, from the University of Rochester Medical Center Department of Neurology Coding Office in Rochester, N.Y. "If there is not a diagnosis that is documented by the physician, codes for documented signs and symptoms of a condition must be assigned." ICD-9 defines signs and symptoms as the following: Cases for which the physician can make no more specific diagnosis even after he has investigated all the facts bearing on the case;  Signs or symptoms existing at the time of the initial encounter that proved to be transient and whose causes could not be determined; Provisional diagnoses in a patient who failed to return for further investigation or care; Cases referred elsewhere for investigation or treatment before the physician could make a diagnosis; Cases in which a more precise diagnosis was not available for any other reason; and/or Certain symptoms that represent important problems in medical care and that the physician might wish to classify in addition to a known cause. A Dx After a Procedure Is Not Always Possible You won't necessarily always report a definitive diagnosis after a procedure or test. You should report a diagnosis when your physician has performed a procedure and the results confirm it. In other words, "you should never assign a diagnosis until its definitive," says Doris Ward, CPC, coder/biller at KY Surgery Center in Lexington, KY. Example: Your physician conducts an EEG and confirms a diagnosis of myoclonic epilepsy. In this case, you should report 345.10 (Generalized convulsive epilepsy; without mention of intractable epilepsy) as the primary diagnosis. However, if your physician performs a procedure and the evidence is inconclusive or negative, you should fall back on reporting the patient's documented signs and symptoms. Example: Your physician conducts a test, but he documents that the results are inconclusive for Parkinson's disease. In this case, you should rely only on the signs and symptoms to establish medical necessity for the diagnostic study your physician performs. "Diagnosis code reporting must match what the provider has documented as the reason for the encounter" says Wink. "The narrative should support the codes and [...]