Pathology/Lab Coding Alert

 Make sure to code the most specific diagnosis
 
You have to know when you should - and when you shouldn't - code the pathologist's diagnosis first. Then remember to report the fourth or fifth digit, when available, and you'll get your ICD9 Codes right every time.
 
Getting the diagnosis code wrong can mean you won't get paid for a service - or that you'll brand a patient with an erroneous medical condition. Learn what our experts say about how you can prevent the following ICD-9 coding errors:

Mistake 1: Not Assigning Pathologist's Diagnosis
 
When the pathologist provides a definitive diagnosis, you should assign the ICD-9 code based on the findings listed in the pathology report, if available at the time of coding. "The principle is to code to the highest degree of certainty," says Pamela Younes, MHS, HTL (ASCP), CPC, PA (ASCP), assistant professor at Baylor College of Medicine in Houston.
 
The April 2005 ICD-9-CM Official Guidelines for Coding and Reporting emphasizes that a physician must interpret the test results before you can code it. The inpatient guidelines say to report diagnostic results if "the provider indicates their clinical significance." The outpatient guidelines say to "code any confirmed or definitive diagnosis(es) in the [physician's] interpretation." That means you should assign ICD-9 codes based on a pathologist's report, but not based on a lab report for a clinical laboratory test that a physician has not interpreted.
 
Once the physician makes a diagnosis, you should no longer report the clinical signs and symptoms that led to a diagnostic test as the primary diagnosis. But if no definitive diagnosis is available, you should list the ICD-9 code given by the ordering physician indicating the signs and symptoms that were the reason for the test.
 
Exception: For inpatient coding, if the physician uses terms such as "probable," "suspected," or "rule-out," you should "code the condition as if it existed," according to the guidelines. "But you should never code inconclusive diagnoses for outpatients - rather, stick to the highest degree of certainty for the encounter, such as signs and symptoms," Younes says. 
 
Watch for: Pathology reports may contain terminology such as "consistent with" or "compatible with," and some coders have questioned whether that wording indicates an uncertain diagnosis, says Laura Edgeworth, HTL, CPC, coding and audit specialist with Pathology Service Associates LLC (PSA), in Florence, S.C.
 
Use of a phrase like "consistent with" does not necessarily mean that the pathologist's diagnosis is uncertain.
 
For instance: If the pathology report describes the microscopic support for cancer and names a specific diagnosis, you should code it, Younes says. You may have to ask the pathologist for clarification if the report lists different conditions and qualifies the cancer diagnosis using a phrase such as "consistent with." For some examples, see "Quick Quiz: Test Your Diagnosis Coding Savvy" on page 42.

Mistake 2: Using Only the Final Diagnosis for Screening Test

Unlike diagnostic test results, if the physician orders a screening test, you have to report the screening ICD-9 code as the reason for the test. "Even if the pathologist makes a definitive diagnosis, you have to code the screening first," Younes says.

Mistake 3: Missing Most Specific Code

Not only should you code to the highest degree of certainty, but you have to code to the highest level of specificity too. That means reporting four- or five-digit codes if available, rather than a less specific three-digit code.

Three-digit codes are called category headings, which ICD-9 may further subdivide using fourth and/or fifth digits. "You should never use a category heading as a diagnosis if a more specific four- or five-digit code is available," says Stacey Hall, RHIT, CPC, CCS-P, RCC, director of corporate coding for Medical Management Professionals Inc. in Nashville, Tenn. That's why you should always check the ICD-9 tabular section (Volume 1) to ensure you're coding to the highest level of specificity.
 
Even if the medical record does not clearly define the diagnosis, you still have specific ICD-9 codes available - the "not otherwise specified" codes - which can have four or five digits. "You have to report a code to the full number of digits required, otherwise the code is invalid," Hall says.
 
Editor's note: Updated ICD-9 guidelines are available at www.cdc.gov/nchs/data/icd9/icdguide.pdf.