Pathology/Lab Coding Alert

Question: When we get orders for a clinical lab test, can we use “symptoms” to assign the diagnosis code?

Codify Subscriber

Answer: Yes, when a physician orders a clinical diagnostic lab test, you should bill the test using the diagnosis that the ordering physician assigns, and that’s often signs or symptoms. The ordering physician may give you an ICD-10 code, which you’re compelled to use, or a narrative diagnosis, which you’ll have to “translate” into the most appropriate ICD-10 code.

In black and white: “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,” according to the ICD-10-CM Official Guidelines for Coding and Reporting.

In fact, you want to be sure that if you don’t have a final diagnosis, you use signs and symptoms, not a “suspected” condition as the diagnosis.

ICD-10 guidelines: “The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.”

ICD-10 establishes this standard to avoid labeling a patient with an unconfirmed diagnosis. By reporting signs and symptoms, you can establish medical necessity for the lab test without reporting an unconfirmed diagnosis.

Watch out: The following phrases in your physician’s documentation can indicate that the physician has not formally diagnosed the patient with the condition or disease:

• Probable
• R/O or rule out
• Working diagnosis
• Suspected
• Likely
• Questionable
• Possible
• Still to be determined.