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Radiology Coding Alert

Diagnosis Coding Dilemma:

Report Findings or Signs and Symptoms

Published on Sun Jul 01, 2001

A debate rages among Radiology Coder about whether they should report diagnosis codes reflecting the findings of a radiological exam -- as opposed to, or in addition to, the signs and symptoms that prompted the exam.

No matter which argument they support, coders must comply with applicable reimbursement policies, which differ greatly from payer to payer.

Coding experts on one side of the issue cite the Balanced Budget Act (BBA) of 1997, noting it states that only signs and symptoms need to be reported. "Direction on this issue has been clearly given in the BBA, which is a law enacted by Congress," says Cheryl Schad, BA, CPCM, CPC, owner of Schad Medical Management, a physician reimbursement and compliance consulting firm in New Jersey, and a nationally recognized speaker on this topic. Under the heading "Requirement to Furnish Diagnostic Information (Section 4317)," the BBA states it "requires physicians and nonphysician practitioners to provide diagnostic or other medical information when ordering certain items or services & in order for payment to be made & " [emphasis added].

This makes sense, she adds, because the Medicare reimbursement system is based on proof of medical necessity. "It doesn't matter what the radiologist finds during the test. Payment should depend on whether the reasons for performing the test support medical necessity."

Others argue that Congress enacted the BBA primarily to give physicians direction about when it is appropriate to order tests. "The law was not intended to provide coding direction," says Susan Prophet, RHIA, CCS, CHC, director of coding policy and compensation with the American Health Information Management Association. "It addresses a much larger issue  that physicians can't order tests if there is no reason for the test."

Many Payers Require Definitive Diagnoses
 
Within this context, it is appropriate for coders to report the results, findings and diagnosis determined by the radiologist if the carrier or insurer requires it. For example, Nancy Wallin, billing specialist with Diagnostic Radiology Associates in Waterbury, Conn., says one carrier's policy includes the following clear-cut example:

A physician refers a patient to a radiologist for a chest x-ray with the reason for the exam identified as cough and fever. The x-ray demonstrates bronchopneumonia. The radiologist should ICD-9 V72.5 (radiological examination, not elsewhere classified) as the reason for the visit and list an additional code for the bronchopneumonia (i.e., 485, bronchopneumonia, organism unspecified). Do not code the cough and fever, as more specific information is available.
 
Although there is no national policy to this effect and coding professionals will continue to find great discrepancies, Prophet says there is a trend toward reporting results. For instance, both the American Hospital Association's Central Office on ICD-9-CM -- which publishes The Coding Clinic, considered the official ICD-9 coding source for Medicare -- and the Medicare Carriers Manual (see MCM B3 4020.3) note that coders should report results or definitive diagnoses established by the radiologist or other physician.

The principle behind this movement is that patient encounters should be coded to the highest degree of certainty, she says. The symptoms of pain and swelling in the wrist (e.g., 719.43) may be documented on the order for an outpatient x-ray of the wrist, for example. If the radiologist's interpretation on the radiology report establishes a definitive diagnosis of fractured wrist (814.00), however, this diagnosis represents the highest degree of certainty for the x-ray and would be reported.
 
Coders must list the diagnosis to the highest level of specificity, as well. If a five-digit ICD-9 code is available for a condition, many payers would reject a related four-digit code. A classic example of a code that always requires a fifth digit is chest pain (786.5). It is already a four-digit code, describing a subcategory of 786 (symptoms involving respiratory system and other chest symptoms), but requires further classification. Code 786.52 indicates painful respiration, for instance.

Prophet also recommends that conditions integral to the disease not be reported in addition to the primary diagnosis. "For example, wheezing is considered integral to asthma and should not be used, even as a secondary diagnosis," she says. In the examples above, pain and swelling are integral to the diagnosis of a fractured wrist, while cough and fever are integral to bronchopneumonia. None of these symptoms would be reported. 

Because payer policies vary greatly, coders must be certain to determine local requirements and consistently assign the ICD-9 codes that comply with carrier guidelines. As always, it is wise for radiology practices to request these requirements in writing.

Note: Coders must recognize that they should not code "rule-out" or "probable" diagnoses. Although this is allowable for hospital services, it is not appropriate for outpatient services.

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