Look for these phrases in your physician's documentation. Typically, your first-listed ICD-9 code is your physician's primary diagnosis. However, if your doctor performs a diagnostic test but offers no confirmed diagnosis, you may need to report the patient's signs and symptoms instead. Balance these factors by confronting four frequent coding issues. Payoff: You'll avoid applying a definitive diagnosis prematurely, which can have long-standing consequences for a patient and the patient's insurance. What Do Signs and Symptoms Entail? Careful:
ICD-9 defines sign and symptoms as the following:
A Dx After a Procedure Is Not Always Possible
You won't necessarily always report a definitive diagnosis after a procedure or test. You should report a diagnosis when your physician has performed a procedure and the results confirm it. In other words, you should never assign a diagnosis until its definitive.
Example:
Your physician conducts an EEG and confirms a diagnosis of myoclonic epilepsy. In this case, you should report 345.10 (Generalized convulsive epilepsy; without mention of intractable epilepsy) as the primary diagnosis.However, if your physician performs a procedure and the evidence is inconclusive or negative, you should fall back on reporting the patient's documented signs and symptoms.
Example:
Your physician conducts a test, but he documents that the results are inconclusive for Parkinson's disease. In this case, you should rely only on the signs and symptoms to establish medical necessity for the diagnostic study your physician performs.››Diagnosis code reporting must match what the provider has documented as the reason for the encounter. The narrative should support the codes and visa versa.
'Rule Out' A Thing of the Past
You should never report "rule out" diagnoses in the outpatient setting. The Official ICD-9 Guidelines have allowances for facilities potentially to report rule outs, but an outpatient neurological practice should not. Rule out codes were themselves "ruled out" years ago.
Resource:
The "ICD-9-CM Official Guidelines for Coding and Reporting" further clarify "rule out" diagnoses (http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf).Watch out:
The following phrases in your physician's documentation can could indicate that the physician has not formally diagnosed the patient with the condition or disease:Outpatient coding rules state only a confirmed diagnosis should be used. In lieu of no confirmed problem in the outpatient place of service, the signs and symptoms under investigation must be coded to support the medical necessity for a diagnostic test.
Official rule:
ICD-9 coding guidelines (Section I B.6. and Section IV. E) state, "Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established [confirmed] by the provider."By taking this approach, you avoid labeling a patient with an unconfirmed diagnosis while still allowing for your doctor's reimbursement for services rendered -- even if he cannot establish a definitive diagnosis through testing.
Your physician's documentation should be strong enough to support the claim with the signs-and-symptoms diagnoses alone, regardless of the outcomes of any diagnostic testing.
Use Symptoms as Additional Dx on Occasion
Occasionally, you'll report sign and symptoms as secondary diagnoses, even if your physician has assigned a definitive diagnosis for a patient encounter. You can report "signs and/or symptoms as additional diagnoses if they are not fully explained or related to the confirmed diagnosis," according to CMS transmittal AB-01-144.
Similarly, you may report signs and symptoms that are not related to the primary diagnosis but affect your doctor's medical decision making or otherwise determine how he formulates a patient's treatment.