Primary Care Coding Alert

Question: A patient says she has had chronic bowel problems for the last 10 years, with diarrhea or loose stool for two to three days in a row, then constipation for another week. Diagnostic tests are being ordered. Because the diagnostic tests are only covered for certain conditions, what diagnosis should be listed? Since this has been her way of functioning for so long, it cannot be considered a change in bowel habits.

New Mexico Subscriber

Answer: This scenario is one of the most frustrating problems for coders limited coverage and unclear diagnosis causing the potential for nonpayment of services. There are several things to review and consider.You must list the patient's condition as accurately as possible based on the physician's analysis of the problem. Diagnoses such as diarrhea (787.91), functional diarrhea (564.5) and unspecified constipation (564.00) are most likely.

If there is documentation of a change of the frequency or intensity of these chronic conditions, change in bowel habits (787.99) could be listed. It is appropriate to question the physician and review the record before assigning the diagnosis codes. In general, functional disorders of the intestines are covered diagnoses for diagnostic tests such as colonoscopy, while nonspecific diarrhea is not covered unless there are other symptoms present as well, such as bleeding or weight loss.

If there is doubt about whether the diagnosis is a covered diagnosis for the procedure, the next step is to inform the patient. Medicare requires the signing of an advance beneficiary notice (ABN) to allow the patient to be an "informed consumer." The form lets them know in advance of the service that the payment for that service may be their responsibility. If they choose to proceed, they must sign the ABN, and the service is submitted to Medicare with modifier -GA(Waiver on file) attached. If the service is subsequently denied, the patient will be fully responsible for payment.

If the patient is not Medicare, but doubt exists as to whether the service is covered, a practice should go through a similar process. Letting patients know in advance (use of a similar form that the patient signs is very helpful) that the service may become their financial responsibility avoids many of the time-consuming and stressful phone calls after the claim has been processed.

The most important thing to remember is that just because a clear diagnosis cannot be determined and entered on the claim form does not mean that the situation is hopeless. Although all practices try to avoid claim denials and working with the appeals department of the payer, this may be the only option.

Often, coding systems do not adequately describe the variables of a patient's condition. If the claim is denied, prepare a brief summary letter from the physician. This letter should be submitted with a copy of the office visit documentation and should describe the combination of issues that were present that prompted the physician to recommend the testing. Keep the letter simple, in layman's terms, so that the appeals department hears your side of the story as clearly and succinctly as possible. This is the key to success in appeals and should work well with many claims that fall into this category.

Answered by Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.