Pathology/Lab Coding Alert

Question: Our pathologists frequently get specimens from physicians with reports that list several signs and symptoms that the patient is experiencing, along with a diagnosis at the top of the note. Should we list all of those diagnosis codes on the claim?

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Answer: Typically, the surgeon or other ordering physician inserts a vague diagnosis on the note, such as “breast mass,” and the pathologist determines the final diagnosis after examining the tissue. If you don’t have a more specific final diagnosis from the pathology report, you may need to report the ordering diagnosis, which could include signs and symptoms.

ICD-10-CM guidelines and CMS provide some instruction about when to report signs and symptoms along with another code, as follows:

CMS: You can report “signs and/or symptoms as additional diagnoses if they are not fully explained or related to the confirmed diagnosis,” according to CMS transmittal AB-01-144. Similarly, you may report signs and symptoms that are not related to the primary diagnosis but affect your physician’s medical decision-making or otherwise determine how he formulates a patient’s treatment.

ICD-10-CM: “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.”

In other words: If the definitive diagnosis doesn’t present a complete picture of a patient’s condition, then you may assign additional signs and symptoms codes in addition to the definitive diagnosis to support your physician’s claim.

On the other hand, if the pathologist’s definitive diagnosis explains or supports the service he provides for the patient, you should not report signs and symptoms in addition to the definitive diagnosis.