Otolaryngology Coding Alert

ICD-9 signs and symptoms codes should be used to provide medical necessity for a procedure or service when there is not a more specific diagnosis available to the otolaryngologist. Although physicians are trained to look for a specific diagnosis, sometimes a patient may have a complaint that cannot be diagnosed right away.

In some cases, the complaint may be gone by the time the otolaryngologist evaluates the patient; in others, no definitive diagnosis can be ascertained before lab tests are returned. For example, an otolaryngologist may excise a mass believing the patient has a lipoma; however, until the pathology report is returned, the otolaryngologist cannot be certain that what was removed was indeed a lipoma, so a definitive diagnosis cannot be made.

In this situation, and many others, signs and symptoms should be reported instead of suspected, or rule-out, diagnoses. This can be difficult for otolaryngologists, because for inpatient billing, they are instructed by hospitals to use suspected and rule-out diagnoses, and it is appropriate for the hospital to bill it as if the patient has that diagnosis. This, however, does not apply to physician component billing, whether inpatient or outpatient, and switching gears may be confusing for physicians. Section 16 of the ICD-9 book includes many such signs and symptoms codes (780-799.9), which should be used if a diagnosis is not available or until a diagnosis can be proven. Similarly, these codes should be used when a pathology report returns negative.

Physicians are not allowed to use suspected or rule-out diagnoses, says Cynthia Thompson, CPC, a coding and reimbursement specialist with Gates, Moore, an Atlanta-based consulting firm. So without a specific diagnosis, they have to use the signs or symptoms that brought the patient to the office and that prompted the physician to perform the rule-out tests.

Often, the otolaryngologists assessment and plan states that certain tests are being performed to rule out other conditions, Thompson says. But rule-outs should never be used to code physician services, so the only thing left for the physician to code is the sign or symptom.

A patient also may come to the office with a complaint, but after the examination, the otolaryngologist finds nothing wrong. For example, a primary-care physician following complaints of a headache may refer the patient to an otolaryngologist. During the examination, however, the otolaryngologist is unable to determine its cause.

In such a scenario, coding what was found (i.e., nothing) is inappropriate. Instead, the sign or symptom (i.e., headache, 784.0) should be coded to provide medical necessity for the exam. Of course, if, during the course of the examination, the otolaryngologist finds something that is more specific, then that diagnosis code should be used. But lacking a specific finding, it is correct and appropriate to bill using the symptom described by the patient as the reason for the visit.

Avoid Labeling the Patient

In some situations, using signs and symptoms codes not only provides more accurate coding but also avoids inappropriately labeling the patient, which can have long-term consequences. For example, if a male patient sees his physician complaining of an unusual irritated lesion, the otolaryngologist may suspect the lesion is cancerous and perform a skin biopsy either to confirm those suspicions or to rule out cancer as a possibility.

In either case, not only would it be incorrect to use malignant neoplasm of skin (239.2) as the diagnosis code to provide medical necessity for the biopsy, but it could severely impact the patients ability to receive health insurance in the future, even if the pathology report returns negative. Instead, a signs and symptoms code, 782.8 (changes in skin texture), might be more accurate and also doesnt label the patient.

Some signs and symptoms codes carry the potential for significant differential diagnoses, some of which also can label the patient. For example, a patient with vertigo (780.4), tinnitus (388.30) and hearing loss sees the otolaryngologist, who may suspect Menieres disease but also wants to rule out an acoustic neuroma. To do so, more tests are required. Meanwhile, only the signs and symptoms should be noted until the tests results return.

This is why history is so important, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs executive committee and editorial panel. From the questions you ask the patient, what you are thinking about can be inferred without putting the diagnosis down in writing.

Eisenberg adds that some diagnoses, such as headache or vertigo, have great potential for differential diagnoses. A patient complaining of a headache, for example, could be having an allergic or tension headache, sinusitis, or a brain tumor, so a wide differential exists for the diagnosis.

Similarly, if a 40-year-old woman reports persistent dizziness for six months, the otolaryngologist may suspect multiple sclerosis, whereas similar vertigo and hearing loss in a younger man would lead the physician to suspect labyrinthitis. So vertigo, too, carries significant differential diagnoses, Eisenberg says.

Coding Chief Complaint

There usually is a reason in the history of present illness or in the chief complaint for the patients visit, Thompson says, and those symptoms justify the medical necessity of the visit. She notes, however, the medical record of the visit must match the signs and symptoms code used when billing for the evaluation and management (E/M) visit. Thompson says this would typically be documented as the patients chief complaint or in his or her history of present illness.

You cannot make up signs and symptoms after the fact, Thompson says. You have to use the signs and symptoms documented in the patients medical record. If the physician noted the patients complaint as shortness of breath, then ICD-9 code 786.05 (shortness of breath) should be used.

Note: If the visit ends with a specific diagnosis, that would replace any signs and symptoms code previously considered.

Signs and symptoms also provide medical necessity for tests ordered by the otolaryngologist. For example, if a patient complains of hearing loss, the otolaryngologist is likely to perform audiologic tests or send the patient to the audiologist for testing. Either way, the sign or symptom justifies the test.

If the otolaryngologist is seeing the patient as a result of a request from a primary-care physician, the signs and symptoms may allow the visit to be billed as a consult, rather than a new patient visit. Had the patient come in with a known disease, the carrier might be more likely to believe a transfer of care occurred and classify the service as a new patient visit. But the signs and symptoms diagnosis indicates the medical necessity for the consult, because it shows the otolaryngologists opinion was required to determine diagnosis and course of treatment.

Thompson also cautions coders using signs and symptoms codes to note any specific exclusions in the ICD-9 book. In addition, she says, some signs and symptoms ICD-9 codes require a fifth digit.

Boost E/M Service Levels

The signs or symptoms codes in the ICD-9 book not only support the need for tests but also can justify higher levels of service, Thompson says, noting that the medical decision-making portion of the E/M services often is boosted when the physician has only a sign or symptom to work with due to the undefined nature of the complaint.

Often, you can cite medical decision-making of moderate or high complexity when using signs and symptoms ICD-9 codes, because the situation increases the number of diagnoses/management options portion of the decision-making category, Thompson says.

The other two components of medical decision-making table of risk and tests ordered and reviewed also are likely to be higher when there is no specific diagnosis, says Kathleen Mueller, RN, CPC, CCS-P, a coding and reimbursement specialist in Lenzburg, Ill. When a problem is undiagnosed, it often means the doctor will have to order tests to try to determine the patients problem, Mueller says. After all, she notes, a specific diagnosis is less likely to call for a wide variety of tests than a sign or symptom because the cause of the symptom is unknown and needs to be discovered.

And since diagnostic procedures ordered is one of the three components of the table of risk, the level of risk may increase because the highest single category of the risk table determines the entire risk component.

Signs and symptoms often relate to more than one health issue in a patient, which also may increase the complexity of the diagnosis and, therefore, the medical decision-making by the otolaryngologist, Eisenberg says.

If a patient with hypertension and cardiac disease who is taking aspirin sees the otolaryngologist for epistaxis, a simple nosebleed may become a complex medical problem because the number of factors under consideration by the physician has increased.

In such a situation, Eisenberg recommends listing all the diagnoses. We tend to be lazy and not do it, but we should, he says.