Coding for Signs and Symptoms to Get Claims Paid and Boost Reimbursement
Published on Tue May 01, 2001
"In the world of ob/gyn care, a distinct diagnosis may be hard to pin down, particularly at the time of the patients initial complaint. Signs and symptoms codes can help classify a visit when no distinct diagnosis can be made, and they may boost reimbursement by increasing the level of decision-making for E/M visits.
ICD-9 codes should be used to describe a diagnosis, symptom, complaint, condition or problem of a patient for the medical service or procedure being billed. Although claims adjusters are trained to look for a specific diagnosis, a patient might have a complaint that cannot be diagnosed right away. When there is not a specific diagnosis available to the physician, the ICD-9 signs and symptoms codes should be used to provide medical necessity for a procedure or service. According to Catherine A. Brink, CMM, CPC, president of Healthcare Resources Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., a code or codes from this group can be valid if it most closely describes the diagnosis. But, these should only be used after checking all other options, Brink says.
Sometimes, a definitive diagnosis cannot be reached before lab or other diagnostic tests are returned, so the physician can only record an ICD-9 code of urinary frequency or urinary urgency, for example, even if he or she suspects stress urinary incontinence. In other cases, test results are normal and a diagnosis cannot be determined. For example, a patient presents to the gynecologist complaining of abdominal pain. The physician completes a pelvic exam and Pap smear, and orders an ultrasound. The ultrasound, done three days later when the ultrasound technician is in the office, does not find any abnormalities to explain the pain. The patients pain subsides, and no more follow-up is scheduled, although she is told to make an appointment if the pain returns.
In the absence of a specific diagnosis, practices can use diagnosis codes listed in the Symptoms, Signs, and Ill-Defined Conditions section of the ICD-9 codebook to prove medical necessity for the visit. In this case, 789.0x (abdominal pain [the fifth digit is required to identify location of pain]) could be assigned to the claim. In a gyn practice, however, some of the codes in the genitourinary chapter of the ICD-9 book also refer to symptoms rather than definitive diagnoses. For instance, category 625 includes codes for pain and other symptoms associated with the genital organs. Code 625.9 (unspecified symptom associated with female genital organs), therefore, can be used if the pain is thought to be pelvic rather than abdominal.
Signs/Symptoms Codes Versus Rule-out Diagnoses
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