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Urology Coding Alert

Coding Diagnostic Tests Issue Has Been Resolved

Published on Thu Nov 01, 2001

The ongoing controversy over whether to use signs and symptoms or the test result to code a diagnostic test has been resolved for the providers performing the tests radiologists, pathologists, laboratories as well as for urologists when they interpret the test results themselves. In general the physician who orders the test should code the symptom that prompted the test, and the interpreting physician should code the result. 
 
The coding guidelines for outpatient services from ICD-9 instruct interpreting physicians to report diagnoses based on test results, according to the program memorandum issued Sept. 26, 2001 (Transmittal AB-01-144). Referring physicians should code the reason, usually a symptom, for ordering the test. The transmittal notes that CMS agrees with these policies.
 
The transmittal doesn't specify whether the referring physician has the option of waiting for the test result to come back before coding the claim. However, industry standard has always left the decision on when to bill up to the individual physician, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services in Denver, Colo. "If the referring physician wants to wait for the results of the diagnostic test before billing, no guidelines would prohibit this," says Page. "But unless the referring physician is billing the test there would be no reason to wait for the results."

Interpreting Versus Ordering a Test

If the physician knows the diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis, the transmittal states. Use signs and symptoms as a secondary diagnosis if unrelated to the confirmed diagnosis.
 
However, the physician who ordered the test should not use the result as the diagnosis code. A physician who interprets a test, whether the physician is the urologist ordering the test or the radiologist or pathologist interpreting it, can make final code assignment. The ordering physician uses the symptom.
 
For example, a urologist sends a patient for outpatient x-rays with a diagnosis of renal colic (788.0). The x-ray diagnosis per the radiologist is "bilateral nephrolithiasis with staghorn calculi" and the code in this case is 592.0 (calculus of kidney). When the urologist gets the radiologist's report, he or she should code the subsequent visit as 592.0 as well.
 
If, however, a laboratory technician, and not a physician, performs and interprets the test, code assignment must be restricted to that made by the referring urologist. For example, the urologist sends a urine speci- men to a lab, and puts "hematuria" (599.7) on the order for the diagnostic test. The pathologist then interprets abnormal cells transitional cell carcinoma of the bladder, and should assign 791.7 (nonspecific findings on examination of urine; other cells and casts in urine) even though that differs from the urologist's order.
 
Note: In an example used in the transmittal, the pathologist interprets the test as 188.9 (malignant neoplasm of bladder, bladder, part unspecified). However, a pathologist would not be able to arrive at such a conclusion based on a urine specimen, says Ferragamo.
 
The transmittal seems to suggest that if the urologist chooses to wait for the pathology report before filing the claim for the visit, he or she may do so. "The referring physician should report 599.7, hematuria, if the result of the cytological analysis is not known at the time of code assignment," the example in the transmittal states. However, despite the confusing wording, coding experts caution that the referring physician should only code what is known at the time the test was ordered and not code the test results.
 
Signs and symptoms codes should be used when a laboratory technician, and not a physician, interprets the test. The technician should also use signs and symptoms codes for the results. The transmittal refers to a patient with a complaint of urinary frequency and burning. The urologist orders urinalysis, and the lab findings are positive for bacteria and increased white blood cells. Based on these findings, the urologist orders a urine culture, which finds  positive for a urinary tract infection.
    
What code should the lab report? According to the CMS transmittal, the fact that no physician is involved in interpreting the test means that the lab should use the same code used by the referring urologist dysuria (788.1). "Since this test does not have physician interpretation, the laboratory (independent or hospital-based) should code the symptoms (i.e., urinary frequency and burning)."

Report the Symptoms

"Basically this transmittal doesn't change what we've been telling urologists," says Cynthia Jackson, RRA, CPC, a Georgia-based urology coder. "Unless the urologist interprets a diagnostic test, he or she, as the referring physician, should report the symptoms that called for the test."
 
Jackson cautions against using, for example, a cancer diagnosis code before you get the pathology back. "No matter how many prostate nodules you've seen, don't code the biopsy until you get the results back," she says. "What if you're wrong, and the pathology report says negative for cancer? You've already assigned a diagnosis to the patient's record that will make it hard for him to get life insurance." Do not wait for the pathology report to come back before assigning the diagnosis, which might be considered fraud, Jackson says.

Screening Tests

Distinguish carefully between tests that are ordered due to signs and symptoms and screening tests. If there is no evidence of illness when you order the test, you must indicate that it is a screening test. If the test subsequently shows a diagnosis, code this as a screening with the finding as a secondary diagnosis.
 
The situation is different if the physician interprets the tests. "In our facility, the physician reads the x-rays and interprets the labs, so for those tests, we would code the result," says Nelda Laskey, RHIT, urology coder with Garden City Medical Clinic in Garden City, Kan. In general, Laskey approves of using the confirmed diagnosis as the primary diagnosis, and the sign or symptom as the secondary diagnosis. In inpatient coding, Laskey says, this is the rule.
 
"The key point is for everyone to be on the same page," says Laskey, referring to all the players: CPT, ICD-9, CMS, local carriers, and private HMOs. "We can code correctly. The question is whose rules do we follow?"
 
Laskey, like many coders, suspects diagnosis-driven payments eventually will apply to physicians as well as to hospitals. "If we don't have our act together by then, we'll lose out on reimbursement," she says.

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