Pathology/Lab Coding Alert

Question: In treating a patient with hypertensive renal failure, the physician ordered serum ferritin. We received a denial for the test when ordered with the physician's diagnosis of 403.01. Should we report the test with a different renal failure ICD-9 code that Medicare covers, such as 585? 

Texas Subscriber Answer: No, you should never change the ordering physician's ICD-9 code selection. If the physician submits a new diagnosis in writing, you can change the code. But the physician can't assign a more general code either, based on the ICD-9 coding rules that require coding to the highest degree of specificity. If the physician diagnoses renal failure caused by hypertension, you must use the appropriate five-digit code from the 403 or 404 categories, not a different renal failure code.

In this case, Medicare comes to your rescue starting April 1. The original National Coverage Determination (NCD) for serum iron studies, including 82728 (Ferritin), did not list ICD-9 codes for hypertensive renal failure as covered diagnoses. The NCD listed other renal failure codes such as 585 (Chronic renal failure). But the NCD did not include codes for renal failure with hypertension. In the quarterly NCD updates, however, CMS will add the following codes as covered diagnoses for serum iron studies:

403.01 -- Hypertensive renal disease; malignant, with renal failure
403.11 -- ... benign, with renal failure
403.91 -- ... unspecified, with renal failure
404.02 -- Hypertensive heart and renal disease; malignant, with renal failure
404.03 -- ... malignant, with heart failure and renal failure
404.12 -- ... benign, with renal failure
404.13 -- ... benign, with heart failure and renal failure
404.92 -- ... unspecified, with renal failure
404.93 -- ... unspecified, with heart failure and renal failure. You can access the CMS decision memo announcing the change at http://cms.hhs.gov/mcd/viewdecisionmemo.asp?id=99.