Select Screening vs. Diagnostic Codes for Maximum Pay Up
Published on Mon May 01, 2000
Once a diagnostic code is established for the treatment of a patient, is it etched in stone or is there a point at which a code can be changed or refined to a more specific diagnosis? What happens when a screening exam results in the diagnosis of a problem? Can that screening code be changed to a diagnostic one? Three key factors affect the choice of codesintent of the visit, change of complaint and documentation of the need for additional tests.
Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., explains some of the subtleties of coding for screening vs. diagnosis, using the following cases as examples.
A patient appears with complaint of abdominal pain. This examination is diagnostic in nature, as the ob/gyn is trying to identify the cause of the complaint. An ultrasound is scheduled for the following week, at which time fibroids are found.
A patient presents for her annual screening Pap smear and pelvic examination. During the course of the exam, she complains of bleeding between periods. The physician suspects the presence of fibroids, and schedules the patient to return for an ultrasound the following week.
These two case scenarios present different but related coding problems and, as Callaway-Stradley says, are a tricky issue. What you are getting into is just how far you can push the diagnosis code to get the highest reimbursement without crossing the line. There is so much confusion with this issue because many coders think that you can never change the diagnostic code from one problem to another. But you can, and its financially constructive for you to do so. Essentially, abdominal pain doesnt pay. Fibroids do. So if the physician is able to diagnose fibroids at the time of the initial examination, use fibroids as your primary code rather than the presenting complaint.
Intent of the Visit Is an Important Distinction
The distinction, explains Callaway-Stradley, is whether the patient appeared with a specific complaint. ICD-9 guidelines state that you can use the diagnosis code that is the most definitive diagnosis as your primary code if you started with some sign or symptom in the patient, she says. But you cant change the code if you started off screening a patient and the screening test results come back two days later showing a problem.
It may sound like a question of semantics, but it is an important distinction. If the patient presented for the collection of a screening Pap specimen, you cannot change the primary code for that visit, no matter what the results are, says Callaway-Stradley. What I have found in my professional experience working with practices is that some practices want [...]
