Otolaryngology Coding Alert

Getting reimbursed for biopsies or diagnostic testing can be difficult because otolaryngologists may be using the wrong diagnosis codes to show medical necessity. By using the post-test diagnosis when coding the procedure, otolaryngologists can increase their chances that an insurance carrier will pay up.

Many otolaryngology coders believe they must use a pre-biopsy diagnosis or indication when they bill for the biopsy that was performed. For example, if a patient diagnosed with chronic dysphagia (787.2, dysphagia, difficulty in swallowing) is sent to the otolaryngologist for a laryngoscopy with biopsy (31535, laryngoscopy, direct, operative, with biopsy), and the biopsy confirms the patient has a tumor, the coder will attach the dysphagia diagnosis (787.2) to the laryngoscopy code, even though dysphagia does not provide medical necessity for the test. Reimbursement will be denied unless a second diagnosisfor example, an edema (478.6, edema of larynx)also is included.

The same problem also extends to diagnostic tests. For example, a family physician sends a patient diagnosed with unspecified hearing loss (389.9, deafness NOS) to the otolaryngologists office for audiologic testing. The test determines the patient has a conductive hearing loss (389.00). The most appropriate code to use would be the most specific diagnosis, rather than an undefined code, says Randa Blackwell, a coding specialist with the Department of Otolaryngology at the University of Maryland in Baltimore, but some codersand carriersinsist that the pre-test diagnosis be used.

Note: In the case of audiologic testing, unspecified hearing loss still would be a payable diagnosis, if not the most accurate one.

Some coders argue that the diagnosis that originally prompted the physician to order the biopsy should be the one attached to the charge for the procedure. They call using the diagnosis from the test results back-coding and are under the impression it is improper. However logical this may seem, it is contrary to Health Care Financing Administration (HCFA) guidelines and often will result in denied reimbursement for tests that should have been paid.

In addition, some third-party payers are insisting that physicians use the pre-test diagnosis code, says Dari Bonner, CPC, CPC-H, CCS-P, president of Xact Coding and Reimbursement in Port St. Lucie, FL. She points, however, to a proverbial mountain of guidelines from Medicare and the American Medical Association (AMA), all of which maintain that it is perfectly legitimateand usually preferableto use the results of the test as the diagnosis to accompany the charge for it.

Post-test Diagnosis More Specific

According to the October 1996 Medicare guidelines on the use of ICD-9 codes, physicians may not use rule-outs or suspected as a reason for performing a diagnostic test. In other words, the test cannot be performed simply to rule out a disease or because an illness is suspected. The ICD-9 guidelines for coding and reporting state: Do not code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosis. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results or other reasons for the visit.

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in North Augusta, SC, notes that the guidelines go on to say, this is contrary to the coding practices used by hospitals and medical record departments for coding the diagnosis of hospital inpatients. According to Callaway-Stradley, this may account for some of the confusion concerning which diagnosis code to use. If the test results return negative, then signs or symptoms would be the only appropriate diagnosis for the test, because rule outs have been disallowed. But what if the test returns positive?

According to the same ICD-9 guidelines, codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when an established diagnosis has not been diagnosed (confirmed) by the physician. But if the test returns positive, then an established diagnosis has been confirmed. The post-test diagnosis provides the highest degree of certainty as required by HCFAs own ICD-9 guidelines and should be used when billing for the testing procedure.

What it all boils down to, Bonner says, is the determination of medical necessity. For example, if the audiologic test mentioned earlier returns negative, indicating the patient has normal hearing, the unspecified hearing loss diagnosis (389.9) would have to be used to provide medical necessity for the test.

But if the test comes back positive and conductive hearing loss is indicated, then the test result canand shouldbe used, because the medical necessity requirements for audiologic testing include conductive hearing loss.

As long as the medical necessity requirements of the tests are met, either signs/symptoms or final results of tests may be used to obtain reimbursement. But using the post-test diagnosis is preferable, Blackwell says, because, according to HCFA guidelines, diagnoses should be coded to the highest degree of specificity.

Our job as coders is to give the best information that we can, and one of the guidelines is that you dont use unlisted or unspecified codes unless they are absolutely necessary and there is no other choice. In these cases where diagnostic testing is being done, there should always be a definitive diagnosis after the testing. Thats just good coding, Blackwell says.