Orthopedic Coding Alert

A new CMS policy that goes into effect Jan. 1, 2002, allows doctors to use either the sign or symptom code or   test results as the reason for ordering the test. This is significant to orthopedic coders and practitioners who perform and bill for ancillary diagnostic services such as MRIs, CSEPS (conscious sedation electrophysiological studies) and EMG/NCS (electromyography/nerve conduction studies). Until now they have not been able to use the diagnosis code as a reason for common tests like MRIs, CAT scans and x-rays.
 
The policy, outlined in CMS Program Memorandum AB-01-144, extends this new rule to both Part A and Part B Medicare recipients and practitioners.

The memo, dated Sept. 26, 2001, clarifies the reporting of the ICD-9 codes for diagnostic tests. The problem, until now, has been two-fold and subject to local Medicare policy. In some states and Medicare jurisdictions, coders could use only approved diagnostic codes to accompany certain tests and CPT procedures. In others, only sign or symptom codes were accepted. Failure to use one of these two methods of coding often resulted in a claim denial or delay in payment.
 
In some states, physicians have been required to choose the diagnosis code based on the outcome of the testing. When a condition was suspected, but not confirmed by the test results, there might not be an approved ICD-9 code to pair with the test code. In other words, the reasoning behind ordering the test might not align with the actual test results. What this can mean for a coder is that using the final diagnosis to code diagnostic tests may result in fewer denials for medical necessity than when you had to rely on signs and symptoms that made the test necessary.
 
In states where only signs or symptoms were allowed for ordering medical tests, the reverse was true. A sign or symptom not on a local medical review policies (LMRP) approved list of codes might not justify ordering an expensive test like an x-ray, CAT scan or MRI. The memo now clarifies that the coder can wait until the test comes back and code the definitive diagnosis rather than the symptom.
  
For example, many patients present with symptoms of numbness and tingling in their arms and wrist. The physician orders an EMG (95860, needle electromyography, one extremity with or without related paraspinal areas) to test for carpal tunnel syndrome. Some carriers would not allow the diagnosis of carpal tunnel syndrome (354.0) to be billed prior to the test results, so it was difficult to get paid with the sign or symptoms. Others might not accept 782.0 (disturbance of skin sensation [numbness]) as a reason for ordering the EMG. The CMS policy memo satisfies both those coding problems by allowing physicians to code for the sign and symptom, as well as the diagnosis from the test result.
 
Terry Fletcher, BS, CPC, CCS-P, an independent coding and reimbursement specialist in Dana Point, Calif., explains that while the fundamental need for a firm diagnosis hasn't changed, the policy permits the physician and coder to present a clearer picture to the carrier of the thought process behind the test orders and ease reimbursement for those claims.
 
The policy shift is especially helpful for orthopedists who have their own MRI facilities. Under the new policy, if the interpreting physician establishes a diagnosis of degenerative tear of the posterior horn of the medial meniscus (717.2) based on review of the MRI, he or she could report that code as the reason for the test with the sign/symptom codes listed as additional diagnoses, i.e., 719.46, knee pain; or 719.66, joint symptoms. Previously, the reason(s) the test was ordered would be reported.
  
CMS outlines the new rules for determining the primary ICD-9 code for testing using the following criteria:
 
"If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis."
 
The problem until now, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J., was that the rules for diagnostic coding for tests were always up in the air. "Do you code the reason for the test, or the result? The new policy affirms that it's OK to code after the test is done," she says.
 
Note: Since the new policy does not go into effect until the beginning of the year, check with your carrier regarding implementation.