Neurology & Pain Management Coding Alert

Signs and symptoms provide a better way

If you're using "rule out" diagnoses to justify in-office diagnostic testing, you're likely facing frequent claim denials and tainting your patients' medical records at the same time. For best results, you should always link CPT testing codes to the signs and symptoms that guide the neurologist's decision-making, coding experts say.

Don't Rely on Unconfirmed Diagnoses

When choosing ICD-9 codes to link to diagnostic tests such as nerve conduction studies (NCS) or imaging procedures such as magnetic resonance imaging (MRI), you should list the signs and symptoms that prompted the neurologist to suspect a particular condition rather than the suspected condition itself.
 
"For example, neurologists commonly consult with patients who exhibit the signs and symptoms of carpal tunnel syndrome," says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver. "To evaluate the patient, the physician will generally conduct NCS and possibly electromyography [EMG]. When you select diagnoses to justify the testing, you cannot rely on 354.0 [CTS] because the condition is not, in fact, known to exist." Instead, Hammer says, you should report any relevant conditions, such as joint pain (719.44, Pain in joint; hand) and enthesopathy (726.4, Enthesopathy of wrist and carpus), as well as such tell-all symptoms as numbness, dryness or "coldness" of the wrist.
 
In a second example, a patient has generalized convulsive epilepsy (345.11) that fails to respond to medication. To rule out other potential problems, such as an aneurysm (747.81) or brain tumor, the neurologist orders further testing, such as MRI or CAT (computer-assisted tomography) scan. "The physician's documentation should substantiate the diagnoses you link to the test," says Bruce H. Cohen, MD, co-director of the Brain Tumor Center at the Cleveland Clinic Foundation in Cleveland. "When the physician is assessing a patient, the term 'rule out brain tumor,' for example, is not appropriate." Therefore, you should report epilepsy (a known diagnosis) as the primary code and list any additional signs and symptoms as the secondary diagnoses. You cannot code for the medical condition that the neurologist is seeking to rule out.

Use Secondary Diagnoses

You should list relevant secondary diagnoses when coding for diagnostic testing. "The more information you provide, the better your justification for additional testing, if required, and the less likely the insurer is to reject the claim," Hammer says. "We usually code up to four diagnoses or symptoms if they are present."
 
For example, when coding a CAT scan for a patient with recurrent convulsions (780.39) and headaches (784.0), report 780.39 as the primary diagnosis, but also list 784.0 in case the neurologist must order additional CAT scans and MRIs. You may report family history codes (V16 to V19) as secondary diagnoses. Keep in mind that family history alone isn't a severe enough diagnosis to justify an office visit.

Assign Post-Test Diagnoses

Don't rely on a suspected condition to justify testing, but when diagnostic testing reveals that a suspected condition does indeed exist, you may report it. CMS transmittal AB-01-144 (effective Jan. 1, 2002) states, "If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis." You may also report the signs and/or symptoms that prompted the physician to order the test as additional diagnoses but only if the confirmed diagnosis does not fully explain those signs and symptoms.
 
Note: Do not report incidental and/or unrelated findings as the primary diagnosis for the diagnostic test or service, even if the findings are more serious than the sign(s) and/or symptom(s) that prompted the test.
 
For instance, when a patient has suspected CTS, the neurologist may record 354.0 as the primary diagnosis if electromyography and nerve conduction confirm the presence of CTS. If the testing does not support a CTS finding, you may still assign signs and symptoms, such as 719.44 or 726.4, to provide medical justification for testing, Hammer says.
 
And you may report follow-up tests using a diagnosis the physician previously confirmed. Consider the following example:
 
A CAT scan shows that a patient has a benign neoplasm of the brain (225.0). The neurologist sees the patient for a follow-up and wants another CAT scan to see if there has been any change. This time, you need only one diagnosis code for this test. "Because the brain tumor is the reason the patient is coming in for the follow-up, it is also the reason for the second CAT scan," says Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J. "As long as the patient is being treated for the benign brain tumor, use the code for the CAT scan as well as for the office visit. If the patient comes in for a follow-up after surgery to remove the brain tumor, and the CAT scan no longer shows any evidence of the tumor, then use diagnosis code V67.0x [Follow-up examination; following surgery]."
 
Use V67.0x for exams following surgery only if the physician finds no new or recurring problems, Brink says. Report the V67 codes for follow-up exams when the patient has healed following treatment. A patient coming in for a six-month follow-up visit for brain-tumor surgery with no recurrence would be V67.0x. "This is not during the healing phase, but after completed treatment. However, if there was a recurrence, you should also use the appropriate code for malignant neoplasm of the brain [191.0 to 191.9 for primary, 198.3 for secondary]," Brink says.

Report V Codes for Screenings

 You should always list the appropriate V code (e.g., V80.0, Special screening for neurological conditions) as the primary diagnosis when coding for screenings. You may report the test results, whether negative or positive, as additional diagnoses, Brink says. For example, if you perform a screening for CTS and the results come back positive, you may list 354.0 as an additional diagnosis with V80.0 as the primary diagnosis.
 
But, with very few exceptions, such as preoperative screenings, Medicare will not pay for screenings even if the test reveals a problem that requires further treatment, because, by definition, a screening involves testing or examination without direct medical evidence that such services are necessary.