Pathology/Lab Coding Alert

Don't fall prey to this incomplete diagnosis pitfall

The pathologist reports -normal cells- and no definitive diagnostic findings--which diagnosis code should you assign?

Do this: In the absence of a confirmed diagnosis, you should report the ordering physician's stated signs and symptoms--and you should expect to get paid.

Code the Most Specific Diagnosis

When your pathologist assigns a diagnosis, you have to use that ICD-9 code, according to Medicare direction. But when your pathologist's findings don't confirm a diagnosis, you should report the reason for the test--and that might be the patient's signs, symptoms or abnormal test results, coding experts say.

Avoid -rule-out-: ICD-9 coding rules state that  you can't use a -rule-out- diagnosis on claims, says Kim Garner Huey, CPC, CCS-P, CHCC, a consultant with KGG Coding and Reimbursement Consulting in Auburn, Ala.

That means you should code signs and symptoms if that's what the doctor uses to order a biopsy that turns out normal, says Rhonda Gudell, RHIT, SCCS-P, CCP, CMBS, with Lakefront Billing Service Inc. in Milwaukee, Wis.

Study This Example

For example: Following an abnormal Pap smear, the pathologist receives a cervical biopsy for -suspected- cervical dysplasia based on -cytologic evidence of malignancy.- The pathologist finds no abnormal cells from the transformation zone, stating that -the specimen exhibits no atypia.-

You cannot assign an ICD-9 code for cervical dysplasia--not even an -unspecified- code such as 622.10 (Dysplasia of cervix, unspecified). Instead, you should report the ordering diagnosis--795.06 (Papanicolaou smear of cervix with cytologic evidence of malignancy).

Watch the 4th and 5th Digit

If the ordering physician provides you with an ICD-9 code that is missing a fourth or fifth digit, don't try to -invent- your own extra digit, experts say. Instead, you might query the physician for the extra digit, Garner Huey says. Failing that, you can try using an -unspecified- code. 

Some payers don't like unspecified codes (which typically end in a fourth digit of 9 or a fifth digit of 0). But if you don't have enough information to assign a more specific fourth or fifth digit, these may be your best option.

For instance: If the ordering physician in the previous example had ordered the biopsy with a diagnosis of -abnormal Pap smear,- which ICD-9 code would you assign?

You should not report 795.0 (Abnormal Papanicolaou smear of the cervix and cervical HPV). Code 795.0 requires a fifth digit, so you-d have to use the unspecified code--795.09 (Other abnormal Papanicolaou smear of cervix and cervical HPV).