Otolaryngology Coding Alert

In the case of screening tests, hospital and physician coders operate under different guidelines that may add to the confusion about which diagnosis code to use for tests of any kind. According to Coding Clinic, the ICD-9 publication used by hospital coders, services that are performed for screening purposes may use the diagnosis discovered during the test as the code for the test.

But Medicare guidelines state that in the absence of illness, injury or symptoms, any test performed is a screening exam and will not be reimbursed, regardless of the outcome of the test, says Dari Bonner, CPC, CPC-H, CCS-P, president of Xact Coding and Reimbursement in Port St. Lucie, FL, which specializes in coding and reimbursement issues.

In other words, physicians must indicate medical necessity for performing tests, while hospitals dont. Therefore, if a patient with a hearing aid comes in for her yearly screening, even if a test finds a significant hearing loss, it would not be covered because the test was initiated for screening purposes.

Differentiating between a screening and other tests, however, is not difficult. If the patient is asymptomatic and receives a test, it is a screening. Whereas, if the patient exhibits signs or symptoms, the test is diagnostic and either signs/symptoms or the final results may be used for the diagnosis code, depending on which shows medical necessity.

Randa Blackwell, a coding specialist with the Department of Otolaryngology at the University of Maryland in Baltimore, adds that otolaryngologists occasionally cause themselves billing problems by beginning an operative report, The patient is a 66-year-old woman who appears to be healthy. When in fact, the patient came to the physician complaining of headaches. To avoid having a test on this patient inadvertently interpreted as a screening, the patients symptoms, not her otherwise good health, should be stressed.

Note: Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, SC, says that regardless of whether the test in question was a screening or diagnostic based on the patients symptoms, practices must code appropriately. This may mean that the insurance carriers occasionally are not going to pay for the tests, she says, and the patient will have to pay the bill. Callaway-Stradley cautions coders not to use diagnosis codes simply to get the carrier to pay for the test procedure, adding that otolaryngology practices should be proactive in efforts to inform their patients that some tests will not be covered by their insurance plans.