Radiology Coding Alert

Connect this symptom code to your procedure to earn payment

When tests come back without a definitive diagnosis, don't relax your usual high standards for searching out the proper diagnosis code. Our experts reveal the steps you should take when coding normal, negative, or inconclusive diagnostic test results.

Problem: For an inconclusive diagnostic test, you shouldn't report a diagnosis that the laboratory gives you after a pathology test, says consultant Maxine Lewis with Medical Coding Reimbursement Management in Cincinnati.

But many practices are tempted to report the lab's diagnosis because that's more likely to get paid.

You also shouldn't report the presumed diagnosis that is the reason for the test, such as a "rule-out" diagnosis, says experienced radiology coder Carrie Caldewey, CPC, coding supervisor for Northern California Medical Associates in Santa Rosa, Calif.

Correct coding solution: Code the signs and/or symptoms that the patient has, says Linda Parks, an independent coding consultant in Marietta, Ga. If you code them completely and carefully, you should get paid.

Example: A patient with right-lower quadrant abdominal pain has a CT to rule out appendicitis. The CT isn't diagnostic of appendicitis. Surgery and a lab report reveal that the patient had a ruptured appendix.

You should report 789.03 (Abdominal pain; right- lower quadrant) for the CT diagnosis, NOT 540.x (Acute appendicitis).

Pull Out Primary Reason for Test
 
When a patient has multiple symptoms, some may be covered for certain tests, while others are not, Parks adds. For example, Medicare will cover a chest x-ray for shortness of breath, but not for abdomen pain. If a patient has both shortness of breath and abdomen pain, you should list shortness of breath (ICD-9 786.05 )--the reason for the chest x-ray--as the test's primary diagnosis if the radiologist doesn't offer a more specific diagnosis.

Resource: For Medicare, you can check your carrier's local coverage determination (LCD) to find out which symptoms and diagnoses are covered for each diagnostic test, Lewis says.

Remember: Medicare and many other payers allow you to report more than one ICD-9 code, so if the patient has more than one sign and/or symptom that led to the order for the imaging test, you may report all appropriate diagnosis codes.

Prevent Payers From Dipping Into Your Pockets
 
Consider asking the patient to sign an advance beneficiary notification (ABN) for the test, Parks says. But only use an ABN when you have a reasonable expectation that your carrier will deny payment.

Explain to the patient that Medicare may not pay for the test and that the patient may be financially liable if Medicare denies the claim.

If your payer does deny claims for interpreting results, you should appeal and try to figure out your insurer's guidelines for tests, Lewis says.

With non-Medicare carriers, you may need to use "trial and error" to figure out which symptoms are acceptable to cover a test because the payers play their cards close to their chests. Remember: "You can't make up a symptom," Parks says. Only report codes your documentation supports.