Part B Insider (Multispecialty) Coding Alert

Question: Oftentimes, we receive documentation from our gastroenterologist that doesn't include definitive diagnoses. What do we report in this case?


Indiana Subscriber

Answer: If the gastroenterologist doesn't confirm a diagnosis, you should report the signs and symptoms, says Alice Church, CCS-P, coding and reimbursement analyst for Wolcott, Wood & Taylor Inc. and chief billing officer for the University of Illinois Hospital Physicians in Chicago.

Example: During an initial consult with a new patient, the gastroenterologist suspects a diagnosis of Crohn's disease (555.9). Until testing or diagnostic services confirm that diagnosis, however, you should rely on signs and symptoms to justify medical necessity for any services the physician provides."

Typical signs and symptoms indicative of Crohn's disease include 787.02 (Nausea), 789.0x (Abdominal pain) and 578.1 (Blood in stool).

Confirmed diagnosis: The gastroenterologist conducts colonoscopy (such as 45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) and confirms a diagnosis of Crohn's disease.

In this case, you should report 555.9 as the primary diagnosis for the colonoscopy and list the signs and symptoms as secondary diagnoses.

ICD-9 coding guidelines state that you should not report "rule-out" diagnoses in the outpatient setting. This approach avoids labeling the patient with an unconfirmed diagnosis while still allowing for reimbursement for the physician, even if testing cannot establish a definitive diagnosis, Church says.

The gastroenterologist's documentation should be strong enough to support the claim with the signs-and-symptoms diagnoses alone, regardless of the outcome of diagnostic testing.
Don't forget: If the gastroenterologist confirms a diagnosis, however, you should report that diagnosis instead of the signs or symptoms that prompted the procedure, according to CMS program memorandum AB-01-144. But that doesn't mean you can't report signs and symptoms when necessary.