Optimize Your Reimbursement for Rule-outs and Screenings
Published on Thu Jun 01, 2000
After ordering a test to rule out a possible condition, a neurologist may encounter a reimbursement dilemma because of a variety of coding possibilities. This scenario can be complicated further if a suspected problem exists rather than the problem ruled out by the testing.
You cant code based on the lab finding or the x-ray alone, says Bruce H. Cohen, MD, co-director of the Brain Tumor Center at the Cleveland Clinic Foundation in Cleveland, Ohio, which has more than 40 neurologists. But, if the diagnosis is not known before the test is done, the claim should be coded based on the signs and symptoms noted by the neurologist when the test was ordered.
Case Example
When a patient has generalized convulsive epilepsy (345.11) that does not respond to medication, the neurologist wants to rule out other medical conditions, such as an aneurysm (747.81) or brain tumor. Cohen asserts that, Selecting the correct code when ordering a test should be substantiated by what is in the physicians note. When formulating an assessment of a patient, the term rule-out brain tumor, for example, is not appropriate. Therefore, code the epilepsy as the primary code and do not code the medical condition that the neurologist is seeking to rule out.
When ordering an MRI or CAT scan for a patient with headaches, the neurologist needs to provide justification in the medical record and a diagnostic code that the insurance company will find acceptable to justify ordering that test. Cohen adds, For example, an electromyogram (EMG) would probably never be a reasonable test for a patient presenting with a headache. Likewise, neurologists do not order MRIs to prove a patient has migraines or tension headaches, they order MRIs for patients with headaches and other historical or physical findings suggestive of the underlying pathology to prove or disprove that suspected illness.
Cohen gives another example: A patient is having a progressive headache disorder in which mild, infrequent headaches occur and are accompanied by nausea and vomiting in the morning. This is suggestive of a brain tumor, he says. A neurologist should do a CAT scan to investigate the possibility of a brain tumor. Insurance companies wont pay for CAT scans for migraines, so if you code the CAT scan as a test for migraine (346.9), its an instant rejection, Cohen says.
Neurologists should avoid using unconfirmed diagnosis codes because insurance companies maintain databases of all these codes. When people apply for life, health or disability insurance, the insurance company will look for any problems the patient may have had in the past. For example, do not use the diagnosis code for a congenital brain aneurysm (747.81) for a CAT scan if [...]
