Primary Care Coding Alert

CMS' recent program memorandum (transmittal AB-01-144) reminded Medicare carriers of the proper ICD-9 codes for diagnostic tests. While the memo reiterates many standard policies, it also clarifies a common confusion by telling practices when it is appropriate to code diagnostic tests based on the results. Family practice coders need to know all the specific ICD-9 guidelines for diagnostic tests or they could face denials and lose out on fair reimbursement.
 
"A lot of the information in the memo was a clarification of basic regulations, but it's a good reminder of proper diagnosis coding for diagnostic tests," says Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians. "Since family physicians perform a lot of diagnostic tests, hopefully they were coding this way already, but if they were making mistakes, it should help them."
 
The following "dos and don'ts'' will help coders avoid the most common pitfalls of coding for diagnostic tests.   
 
1. Don't code the symptoms as primary for results with a confirmed diagnosis. "The CMS memo clarified a lot of misconceptions about coding for diagnostic tests," says Kathy Pride, CPC, CCS-P, HIM, applications specialist with QuadraMed, a national healthcare information technology and consulting firm based in San Rafael, Calif. "There was an argument in the coding world between those who thought you could never code a diagnostic test based on the test results and those who thought you could. The memo made it clear that you can and should code based on the results when there is a physician's confirmed diagnosis." 
 

Do code the ultimate diagnosis once you get the results of the test. Use the initial symptoms that prompted you to do the test as secondary coding. For example, a patient presents with a suspicious cough, and the FP performs a chest x-ray in the office.  The x-ray reveals pneumonia. In this case, report a diagnosis of pneumonia (e.g., 481, pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]) and sequence "cough" (786.2) as an additional diagnosis, Moore says.

2. Don't code for the suspected problem when the test comes back normal.  When an FP finds normal results in a diagnostic test, some coders make the mistake of coding for the suspected problem. For example, a patient complains of chest pain, and the physician suspects gastroesophageal reflux disease (GERD). The physician performs an EKG that produces normal results. Some coders use 786.5x (symptoms involving respiratory system and other chest symptoms; chest pain) for the chest pain and 530.81 (other specified disorders of esophagus; esophageal reflux) for the suspected GERD, but this is incorrect. Coders can only report a definitive diagnosis, and in absence of one, they must report the signs and symptoms only. 
 

Do code with the signs and symptoms that prompted the test when a diagnostic test comes back normal. Even if the FP documents signs of uncertainty (e.g., probable, suspected, questionable, rule out or working) before the diagnostic test, reporting the signs and symptoms that prompted the test is still the only appropriate coding, Moore says. The correct diagnosis code for the above example is 786.5x because it is the only explicit reason for the EKG. Although suspicion of GERD was part of the impetus for performing the EKG, the physician never made a definitive diagnosis of GERD and cannot code for it.

3. Don't report incidental findings as primary. Sometimes when an FP conducts a diagnostic test, results reveal a problem separate from what the patient was being tested for. Some coders list the incidental diagnosis first and the symptoms that prompted the test second. Do not report results as primary because they represent an ultimate diagnosis. Results can only be listed as primary if they match the reason for the test.
 

Do report symptoms as primary if the test comes out normal and incidental findings as secondary. For example, a patient presents with wheezing, and the FP does a chest x-ray. The x-ray is normal except for scoliosis and degenerative joint disease of the spine. In this case, report wheezing (786.07) as the primary diagnosis because it was the reason for the test, and you may report the incidental findings scoliosis (e.g., 737.30, scoliosis [and kyphoscoliosis], idiopathic) and degenerative joint disease of the spine (e.g., 721.90, spondylosis of unspecified site, without mention of myelopathy) as additional diagnoses.
 
If the test results are abnormal and the physician finds incidental problems, report the definitive diagnosis as primary, the incidental findings secondary, and the symptoms that prompted the test last. Using the above example, if the x-rays showed emphysema, the coder would report 492.x (emphysema) for the definitive diagnosis, 737.30 and 721.90 for the incidental findings, and 786.07 for the symptoms.

4. Don't report unrelated or chronic conditions as primary. A claim for a diagnostic test that does not list the reason for the test or the definitive diagnosis as primary may be fraudulent, Pride says. Chronic conditions are important to list, but make sure the carrier doesn't think they are the main motivation for the test.
 

Do report unrelated or chronic conditions as secondary. Coders should report the definitive diagnosis first and the chronic condition(s) second. For example, a patient presents with joint pain for which the physician does an x-ray. Results indicate rheumatoid arthritis. The physician also finds that the patient has chronic hypertension and congestive heart failure (CHF). Report the arthritis (714.0, rheumatoid arthritis) first and hypertension (e.g., 401.1, essential hypertension; benign) and CHF (e.g., 428.0, congestive heart failure) as secondary. If the test is normal, code for the symptoms (e.g., 719.4, pain in joint) first and the chronic condition(s) second.

5. Don't mistake screening tests for diagnostic tests. When an FP orders a diagnostic test in the absence of signs and/or symptoms, it is considered a screening test. "One of the few times you don't code for the results of the test is when it's a screening," Pride says. "However, according to CMS, you may list the results of the test as a secondary diagnosis."
 

Do show the payer that you are conducting a screening. Coders should report the reason for the screening as the primary diagnosis. Results of the test should be coded as an additional diagnosis. "The reason you do a screening is not because the patient has a disease but because it's part of an annual check," Moore says. "In the absence of signs and symptoms, the diagnosis code needs to indicate that it is a screening and not a diagnostic test." FPs often perform prostate cancer screening on male patients aged 50 or older. The patient does not need to have signs or symptoms to warrant the test; it is a screening covered annually. Coders should use V76.44 (special screening for malignant neoplasms, prostate) as the diagnosis code for the prostate screening. Even if test results are positive for prostate cancer, use the V code. 

Each of the examples above assumes that the same physician is interpreting the diagnostic test and making the diagnosis. However, sometimes FPs refer patients to other physicians, e.g., radiologists, for diagnostic tests. When that occurs, remember that 4317(b) of the Balanced Budget Act requires referring physicians to provide diagnostic information to the testing entity at the time the test is ordered for Medicare patients. When an FP refers a patient to another physician for a diagnostic test, he or she should code for the office visit and the signs and symptoms that prompted the test. The physician or laboratory that interprets the test will code for the results when a diagnosis is determined.
 
Note: The CMS program memorandum also discusses the importance of diagnosis coding to the highest degree of specificity. Coders should always make sure the ICD-9 code provides the most accuracy and completeness. The memo is available at www.hcfa.gov/pubforms/transmit/ab01144.pdf.