Neurology & Pain Management Coding Alert

Find out which diagnosis code to connect to your procedure

When tests come back without a definitive diagnosis, don't relax your usual high standards for searching out the proper diagnosis code. Our experts reveal the steps you should take when coding normal, negative, or inconclusive diagnostic test results.

Identify the Problem

For an inconclusive diagnostic test, you shouldn't report a diagnosis that the laboratory gives you after a pathology test, says consultant Maxine Lewis with Medical Coding Reimbursement Management in Cincinnati.
 
But many practices are tempted to report the lab's diagnosis because that's more likely to get paid.
 
You also shouldn't report the presumed diagnosis that is the reason for the test, such as a -rule-out- diagnosis, says experienced radiology coder Carrie Caldewey, CPC, coding supervisor for Northern California Medical Associates in Santa Rosa, Calif. In the absence of a definitive diagnosis, be sure to use the signs and symptoms that prompted the test.
 
Correct coding solution: Code the signs and/or symptoms that the patient has, says Linda Parks, an independent coding consultant in Marietta, Ga. If you code them completely and carefully, you should get paid.

Check Out this Neuro Example

A patient presents with complaints of syncope. The neurologist orders an EEG, which turns out negative. Further determination reveals that the patient has tetralogy of Fallot, a congenital condition. The tetralogy of Fallot diagnosis alone doesn't medically justify the brain mapping tests.
 
You should report 780.2 (Syncope and collapse) for the EEG as the primary diagnosis code, not the tetralogy of Fallot code (745.2). You may include 745.2 as the secondary diagnosis.

Pull Out Primary Reason for Test

When a patient has multiple symptoms, some may be covered for certain tests while others are not, Parks says.
 
Resource: For Medicare, you can check your carrier's local coverage determination (LCD) to find out which symptoms and diagnoses are covered for each diagnostic test, Lewis says.
 
Remember: Medicare and many other payers allow you to report more than one ICD-9 code, so if the patient has more than one sign and/or symptom that led to the order for the imaging test, you may report all appropriate diagnosis codes.

Prevent Payers From Dipping Into Your Pockets

Consider asking the patient to sign an advance beneficiary notification (ABN) for the test, Parks says. But only use an ABN when you have a reasonable expectation that your carrier will deny payment.
 
Explain to the patient that Medicare may not pay for the test and that the patient may be financially liable if Medicare denies the claim.
 
If your payer does deny claims for interpreting results, you should appeal and try to figure out your insurer's guidelines for tests, Lewis says.
 
Tactic: With non-Medicare carriers, you may need to use -trial and error- to figure out which symptoms are acceptable to cover a test because the payers play their cards close to their chests. Remember: -You can't make up a symptom,- Parks says. Only report codes your documentation supports.