Otolaryngology Coding Alert

Medicare carriers across the nation have long differed on whether physicians who perform diagnostic tests should use the diagnosis revealed by the test or the sign or symptom that prompted the physician to order the test in the first place. The Centers for Medicare and Medicaid Services (CMS, formerly HCFA) has ruled that the posttest diagnosis should be used.
 
A CMS transmittal (AB-01-144) issued on Sept. 26 states: "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 transmittal specifically cited guidelines in the ICD-9 Manual and in Coding Clinic, an authoritative facility coding guide published by the American Hospital Association.
 
If the test is normal, otolaryngologists should use the sign or symptom that prompted the test, CMS says. The transmittal also reiterates the longstanding ICD-9 guideline that rule-out diagnoses are not permitted. Therefore, otolaryngologists should avoid using terminology that reflects uncertainty, such as "probable," "suspected," "questionable," "rule out" or "working."
 
Diagnostic tests for screening, however, are not permitted even if the test reveals a problem that requires further treatment. Medicare carriers will not pay for screening tests even if they show problems that need attention. Physicians are instructed to report the reason for the test (i.e., screening, V73.x-V82.x) as the primary diagnosis. The results of the test, whether negative or positive, may be recorded as additional diagnoses.
 
Note: Section #4317(b) of the Balanced Budget Act specifies that referring otolaryngologists are required to provide diagnostic information to laboratories or other testing entities. The information may be communicated in a written document, an e-mail or a phone call.

The pre- or posttest diagnosis issue has long troubled coders, who are trained to code to the highest level of specificity. Some payers, such as WPS, the part B carrier in Illinois, Michigan, Minnesota and Wisconsin, have insisted that physicians link pretest signs or symptoms to their diagnostic test CPT codes even though the posttest diagnosis is typically more specific and accurate.
 
The CMS instructions that posttest diagnoses should be used means that coding such tests is similar to coding biopsies. When the otolaryngologist takes a biopsy and sends it to the pathology lab, the claim form (containing the linked diagnosis) should not be sent until the lab has issued its report and the state of the sample is known. Some offices circle a "diagnosis" choice of  "WAIT" to make sure the pathology diagnosis is back before the claim is processed.
 
For example, if the otolaryngologist sees a patient diagnosed with chronic dysphagia (787.2, dysphagia, difficulty in swallowing) and performs a laryngoscopy with biopsy (31535, laryngoscopy, direct, operative, with biopsy), and the biopsy confirms the patient has a tumor, the tumor diagnosis not the dysphagia is the most appropriate diagnosis to associate with the laryngoscopy. What has long guided coding involving biopsies now also applies to diagnostic tests.
 
The diagnostic test issue affects otolaryngologists less than many other specialists, such as radiologists and cardiologists, who perform and interpret many tests. However, otolaryngology practices that provide audiology and/or allergy testing for Medicare patients in states where pretest diagnoses were requested are likely to welcome the CMS ruling.
 
For example, an otolaryngologist in Illinois whose practice includes an audiologist treats a 72-year-old female patient with unspecified hearing loss (388.40, abnormal auditory perception, unspecified). The otolaryngologist sends the patient for audiologic testing (in this case, 92568, acoustic reflex testing), which reveals conductive hearing loss (389.0x). The otolaryngologist then discusses the option of a hearing aid with the patient.
 
The CMS transmittal finally clarifies that effective Jan. 1, 2002, the most specific diagnosis code, i.e., the conductive hearing loss, should be used regardless of state, says Michelle Logsdon, CPC, CCS-P, a coding and reimbursement specialist in Toms River, N.J. Until now, some carriers, i.e., WPS, required that the pretest diagnosis (unspecified hearing loss) be used.
 
Underlying this issue, as always, is being able to provide the medical necessity for the procedure. Had the audiologic test referred to earlier returned negative, the abnormal auditory perception diagnosis would have to provide medical necessity for the test.
 
In this case, the test returned positive for conductive hearing loss. Because the medical-necessity requirements for acoustic wave testing include conductive hearing loss, this diagnosis can and should be associated with the test code, 92568.
 
The change may not greatly affect reimbursement for otolaryngologists. In the example above, abnormal auditory perception would likely be an acceptable diagnosis for acoustic reflex testing. Other carriers may not have issued local medical review policies on audiology testing that restrict certain diagnoses.
 
The new CMS guideline applies a basic coding principle that diagnosis and procedure codes be selected to the highest level of specificity to procedure billing, allowing the most appropriate diagnosis to be linked to the appropriate diagnostic test code, Logsdon says.
 
Note: Incidental and unrelated findings should not be reported as the primary diagnosis for the diagnostic test or service even if the findings are more serious than the sign or symptom that prompted the test, the CMS transmittal says.