Urology Coding Alert

One fundamental concept should drive your bladder scan ICD-9 Coding: Bladder scans are diagnostic tests. When there isn't a national policy issued by the Centers for Medicare & Medicaid Services (CMS) outlining the covered diagnosis codes for a procedure and you must constantly figure out which diagnosis codes will be acceptable for a given procedure, it is a good idea to stick with what you already know. Use the standard requirements for coding diagnostic tests issued by CMS in September 2001 to guide your diagnosis coding for the new bladder scan code 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging). Grasp the Diagnostic Test Dx Basics How you assign diagnosis codes for diagnostic tests really depends on whether you submit the claim for the ordered test before or after the physician has received or interpreted the results of the test. If the physician who ordered the test has not received the results of the test, the patient's diagnosis code should reflect the signs and symptoms the patient presented with. Proper diagnosis coding requires you to code the reason the patient came in the door, not necessarily what you found when he got there, says Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C. On the other hand, if the physician who ordered the test receives and interprets the results of the test to determine a definitive diagnosis for the patient before the claim has been sent to the carrier, that physician should use a diagnosis code to represent the results of the test unless the results of the test are negative. Never use negative, or normal, test results as the reason for ordering the test. If the test does come back negative, code the signs and symptoms that prompted the physician to order the test.

According to CMS Program Memorandum AB-01-144, Medicare has taken the following stance on assigning diagnosis codes for diagnostic services:
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 diagnoses if they are not fully explained or are related to the confirmed diagnosis.
If the diagnostic test did not provide a diagnosis or was normal, the interpreting physician should code the signs or symptoms that prompted the treating physician to order the study.
If the results of the diagnostic test are normal or non-diagnostic, and the referring physician records a diagnosis preceded by words that indicate uncertainty (e.g., probable, suspected, questionable, rule out, or working), then the interpreting physician should not code the [...]