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Radiology Coding Alert

Signs & Symptoms Versus Findings:

ICD-9 Coding for Diagnostic Tests Also Clarified

Published on Thu Nov 01, 2001

CMS also recently issued Program Memorandum B-01-61 clarifying whether signs and symptoms or definitive diagnoses (findings) should be reported when conducting diagnostic tests.
 
Historically, radiology coders have been split into these two camps: those who believed they should report only the symptoms that prompt the diagnostic test (e.g., severe cough in a patient getting a chest x-ray), and those who believe they should report the radiological findings (e.g., a diagnosis of pneumonia in the same patient). "The memorandum from CMS now makes it quite clear," says Charla Prillaman, CPC, CHCO, senior coding consultant with Webster, Rogers & Co. in Florence, S.C., and the American Academy of Professional Coders 2000 Coder of the Year. "We are to code the diagnosis."
 
In fact, PM B-01-61 states, "If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnosis if they are not fully explained or related to the confirmed diagnosis." CMS provides the example of a patient with a diagnosis of abdominal pain being referred for a CT scan. The radiologist finds an abscess. Coding might include CPT Codes 74170 (computerized axial tomography, abdomen; without contrast material, followed by contrast material[s] and further sections), supported by ICD-9 Code 567.2 (other suppurative peritonitis).
 
CMS notes that signs and symptoms would be reported as the reason for a diagnostic test if results were normal or did not produce a definitive diagnosis, e.g., no pneumonia was found in the patient presenting for a chest x-ray. This same rule applies if the treating physician orders a diagnostic test to "rule out" a condition or to confirm a "probable" diagnosis, and the results of the test are normal.
 
Prillaman says local carrier policy in this regard has varied widely from region to region. "We anticipate that this memorandum will prompt all carriers to adopt this policy. If radiology coders find that claims are denied if the definitive diagnosis is reported, they should appeal."
 
Thomas W. Greeson, a partner with Reed Smith, LLP in Falls Church, Va., whose client base is comprised of diagnostic-radiology groups, and formerly the general counsel for the American College of Radiology (ACR), adds that the memorandum contains a second piece of good news. "CMS also states that it is appropriate for the radiologist to obtain information about the purpose of the diagnostic test directly from the patient," he says. "This is significant because many local carriers have been reluctant to accept diagnoses based on information the patient provided the radiologist." The Program Memorandum indicates that it is preferable for the information to come from the treating physician but, if the referring physician is unavailable, the radiologist may get it from the patient and confirm the information later.
 
Note: Many Medicare carriers emphasize that only the radiologist, not radiology technologists or front-desk personnel, is qualified to obtain diagnostic information from the patient.
 
Other significant items contained in the memo include confirmation that incidental findings should never be listed as the primary diagnosis, and that unrelated and coexisting conditions may appear as additional diagnoses. Finally, CMS states that when diagnostic tests are ordered in the absence of signs, symptoms or evidence of illness/injury, the radiologist should report the reason that the test was ordered, e.g., screening.

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