Secondary Diagnoses Critical To Maximize Reimbursement
Published on Mon May 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 Cohen, MD, co-director of the Brain Tumor Center at the Cleveland Clinic Foundation in Cleveland, 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 is nonresponsive to medication, the neurologist wants to rule out other medical conditions, such as 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.
When ordering an MRI or CT scan for a patient with headaches, the neurologist needs to provide justification in the medical record, as well as provide an acceptable diagnostic code that the insurance company will find is a justifiable cause for ordering that test, he says.
Cohen adds, An 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 underlying pathology to prove or disprove that suspected illness. Therefore, code the epilepsy as the primary code and do not code the medical condition that the neurologist is seeking to rule out.
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, Cohen 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, its an instant rejection, he says.
Neurologists should avoid using unconfirmed diagnosis codes because insurance companies maintain databases of such codes. When people apply for life, health or disability insurance, the insurance company will look for any problems they had in the past. For example, do not use the diagnosis code for a congenital brain aneurysm (747.81) for a CAT scan if the signs and symptoms were for [...]
