Medicare Compliance & Reimbursement

No diagnosis? No problem, Code signs and symptoms -- and get paid.

In the absence of a confirmed diagnosis, you should report signs and symptoms--and you should expect to get paid.

When your physician confirms a diagnosis, you have to use that ICD-9 code, according to program memorandum AB-01-144 from 2002. But when your physician doesn't specify a diagnosis, you should report the patient's signs and symptoms, coding experts say.

ICD-9 coding rules state that you can't use a "rule-out" diagnosis on claims, says Kim Garner Huey, a consultant with KGG Coding and Reimbursement Consulting in Auburn, AL. You should code signs and symptoms--but only if there's no definitive diagnosis.

Example: An oncologist examines the patient for suspected stomach cancer (151.x, Malignant neoplasm of stomach). Your oncologist documents "Rule out stomach cancer" in the medical chart. You can assign other symptoms, such as "blood in stool" (578.1) and "abdominal pain" (789.0x), if documented, to describe the patient's symptoms in the absence of a stomach-cancer diagnosis.

You could also code signs and symptoms if your doctor orders a test and it comes up negative, notes Rhonda Gudell with Lakefront Billing Service in Milwaukee, WI. For example, a patient turns up with a productive cough and fatigue. The physician orders a chest X-ray to rule out pneumonia, but the X-ray comes up clear. So you use the cough as the diagnosis.

If your doctor provides you with an ICD-9 code that is missing a fourth or fifth digit, don't try to "invent" your own extra digit, experts caution. Instead, you should query your doctor for the extra digit, Garner Huey says. Failing that, you can try using an "unspecified" code. 

"Don't waste your time submitting the incomplete code the doctor used," Garner Huey adds. "It will probably not even pass your billing software edits and would just be denied by Medicare even if it did."

"I would never submit a 'guessed' missing digit," says Gudell.

Some payors don't like unspecified codes (which end in .9). But if your physician can't confirm a definitive diagnosis, these may be your best option, notes Christina Neighbors, charge capture reconciliation specialist and coder with St. Joseph Heart & Vascular Center in Tacoma, WA.

If the physician provides different pre-operative and post-operative diagnosis codes during a procedure, always use the post-operative diagnosis codes, Neighbors advises.