Otolaryngology Coding Alert

Signs and symptoms may be your best — or only – choice.

Your first step in filing any claim is choosing the correct CPT^® procedure code, but selecting the appropriate diagnosis code(s) is equally important. Watch these three areas to ensure you’re properly coding patients’ signs, symptoms and diagnoses — and keeping your claims on track.

Don’t Miss 4th- and 5th-Digit Requirements

Reporting precise diagnosis codes starts with your providers being specific in their documentation. You can’t justify a service with a four-digit diagnosis code when payers or ICD-9 requires a more specific five-digit code to describe the patient’s condition.

Pitfall: Don’t assume symptoms that aren’t in the medical record. For example, if you’re coding for temporomandibular joint (TMJ) disorder, you cannot simply report 524.6 (Temporomandibular joint disorders) because four digits alone don’t provide a complete diagnosis. Instead, look further down the code choices for a more appropriate five-digit diagnosis such as 524.62 (Arthralgia of temporomandibular joint).

But you also cannot jump to 524.64 (Temporomandibular joint sounds on opening and/or closing the jaw) simply because the patient mentioned it as she chatted with the receptionist during check-in. Follow your physician’s documentation when selecting diagnoses.

Tip: If the medical record doesn’t allow you to code to the required level of specificity, check with the reporting physician for guidance.

Watch Out for Signs and Symptoms

When your physician provides a confirmed diagnosis, always report that diagnosis instead of the presenting signs and symptoms. If the physician cannot document a definitive diagnosis, however, report the patient’s signs and symptoms to support medical necessity for services the physician provides.

Avoid “rule outs”: ICD-9 coding guidelines state that you should not report “rule-out” diagnoses in for physician services. Terms in your provider’s documentation such as “suspected,” “probable,” “questionable,” and the like aren’t codeable. Steering clear of these possibilities means you’ll avoid labeling the patient with an unconfirmed diagnosis, and by coding the presenting signs and symptoms, your surgeon will still get paid for his services, even if he cannot establish a definitive diagnosis.

CMS confirms this approach by explicitly stating in guidelines that practices should not use the condition being ruled out as the diagnosis. Instead, “code the condition(s) to the highest degree of certainty for that encounter/visit such as symptoms, signs, abnormal test results ...”

Pointer: Talk to your physicians about how important accuracy with their terms is. Tell the physician that if she can come to a definite conclusion about the patient’s diagnosis, she needs to state this in her dictation so you may choose the best code.

Call On V Codes As Applicable

Coders might hesitate to report V codes, but sometimes this section of ICD-9 most accurately describes the reason for the patient’s condition. Actually, you should use V codes to provide additional clinical information to an insurer, whether it’s Medicare or a private payer.

Most coders believe that V codes are only appropriate as secondary codes, but the reality is that you may — and, on occasion, should — report V codes as a primary diagnosis. In some instances, a V code may even be the only way to be paid for a service.

How you know: Many versions of the ICD-9 manual indicate whether you can report a V code as a primary or secondary diagnosis using the designations “PDx” (primary) and “SDx” (secondary) beside the code descriptor. For example, you can report V72.84 (Pre-operative examination, unspecified) as a primary diagnosis, but only submit V15.1 (Other personal history presenting hazards to health; surgery to heart and great vessels) as a secondary diagnosis. If the code has neither a “PDx” nor an “SDx” designation, you may use that V code as either a primary or a secondary diagnosis, according to ICD-9 instructions.