Eli's Rehab Report

PM&R practices that submit diagnostic testing claims before determining firm diagnoses should use the "Symptoms, Signs and Ill-Defined Conditions" codes (780-799.9) to demonstrate medical necessity and reduce claim denials.

Demonstrate Need for Testing

Signs and symptoms codes, found in Section 16 of the ICD-9 manual, can help explain why you performed testing. For instance, many carriers reimburse electrodiag-nostic testing fees (such as electromyograms [EMGs, 95860-95872] or nerve conduction studies [95900-95904]) for diabetic patients with neuropathy, but the diabetes diagnosis alone (250.xx) will not support medical necessity. Because you won't know whether the patient has neuropathy until after the physiatrist reads the test results, you should append signs and symptoms codes to the diabetes ICD-9 to justify the need for testing.

Symptoms such as loss of coordination (781.3) or numbness and tingling (782.0) show the carrier a clear picture of why the diabetes patient required the tests.

Regardless of the test results, carriers should reimburse your practice for the claims because you showed them why the physiatrist suspected diabetic neuropathy (250.6x).

Justify Negative Test Results

Often, diagnostic testing reveals that patients do not have suspected conditions, and the signs/symptoms codes can help increase the chances of reimbursement for these claims as well. "If the practice performs a nerve conduction study for a patient suspected of having carpal tunnel syndrome (354.0) and no concrete diagnosis comes back, then I would use the signs and symptoms codes to show the carrier why the practice performed the test," says Diane Larrivee, CPC, who bills for one PM&R practice at Accurate Medical Billing in Falls Church, Va.

Suppose a patient suspects she has osteoporosis (733.00-733.09) because she is one inch shorter than she was the previous year. The physiatrist finds no sign of osteoporosis and therefore codes the visit with 781.91 (Loss of height). Do not code such claims with an osteoporosis diagnosis because Section 4020 of the Medicare Carriers Manual dictates that you should never code suspected or probable diagnoses.

As of Jan. 1, 2002, CMS requires practices to code either the confirmed diagnosis or, in its absence, the symptoms that prompted the testing.

CMS transmittal AB-01-144 states, "The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis." These should follow the primary diagnosis.

Signs and Symptoms Help E/M Coding

"In some instances, signs and symptoms codes can help show the insurer why you are billing a higher level of E/M," says Sahdna Dru Elliott, assistant administrator at Howell Medical Management, a healthcare reimbursement consulting firm in Los Angeles.

Elliott suggests that multiple signs and symptoms can prompt a more complex level of medical decision-making and cause physicians to spend more time with patients to determine the right types of tests. "If the patient truly suffers from several undiagnosed problems, you may be able to justify a higher-level E/M code."

This does not mean that every patient with multiple symptoms is a 99214 or 99215 (Outpatient established patient E/M visits). But documenting every symptom can help show why the physiatrist feels that your patient visit justifies a high level of E/M service.

Nonspecific Findings are' Signs'

Also included in the signs and symptoms category are Nonspecific Abnormal Findings (790-796), such as 794.17 (Abnormal electromyogram [EMG]) and 796.1 (Abnormal reflex), which should be assigned to help paint a full picture of why you performed certain tests on patients.

For instance, if you performed an EMG on a patient and the results came back inconclusive but were not normal, you may choose to perform a second EMG, for which you would code the original symptoms prompting the first EMG along with 794.17 to show why you repeated the test.