Primary Care Coding Alert

Question: Should we assign a diagnosis code based on the symptoms that a patient presented with, or based on what the physician determined is the cause of the symptoms? For instance, if a child comes in with fever and the family physician concludes the fever is caused by an ear infection, which code would we assign?

New Mexico Subscriber

Answer: It depends. For an office visit, practices traditionally assign a diagnosis code reflecting the findings. However, if the physician orders further tests to determine the cause, the signs and symptoms are most often used. For instance, report ICD-9 code 382.9 (unspecified otitis media) with the E/M service provided to the child above rather than the code for high fever (780.6). If an elderly man presents with shortness of breath, and an x-ray determines the cause to be pneumonia, 786.05 (shortness of breath) would be reported as the primary reason for the study.
 
This issue is being debated, and increasing numbers of local Medicare carriers and private payers are accepting findings (in the case of the x-ray above, 485, bronchopneumonia, organism unspecified) as the reason for further tests. The reason for this change is the philosophy that patient encounters should be coded to the highest degree of specificity possible. Because payer policies vary greatly, coders should determine local requirements and assign the ICD-9 codes that comply with guidelines.