Wiki Diagnosing on objective findings vs diagnostic

[stephthomas]

Heres a ? from our MD:
Dr. R would like to know if we can diagnose something (that is use a diagnosis code that requires an objective finding according to its definition) without objective findings? For example:

A young girl comes in who has chronic neck pain for one year from whiplash during a car accident. Her x-ray is normal, yet she complains of neck pain. What diagnosis code should be used for the facet pain to proceed to medical branch blocks? Then to proceed to a radiofrequency? All of the codes associated with 721.0 (which is what we would usually use) have ?spondylosis? in the definition. However, spondylosis is a condition that must be diagnosed with an x-ray.

For facet pain, a lot of times it is diagnosed because of the patient?s clinical history even when the imaging doesn?t show any abnormalities. However, most of the definitions of the new codes use terms like ?spondylosis? that is a condition that is diagnosed with an x-ray. What codes would we use if the imaging doesn?t show an abnormality?

Anyone have ideas if you MUST have diagnostic proof of abmornality on xray for facet disease? Arent the patients exams and symptoms enough for a definitive diagnosis?

 

[Cynthia Hughes]

There are a couple of different things to think about here.

The physician may want to look to national guidelines for the specified condition to be sure of what findings are necessary for diagnosis under current guidelines. An example would be the guidelines of the National Imaging Associates for facet joint pain diagnosis and treatment - http://www1.radmd.com/media/622489/2014-nia-standard-clinical-guidelines.pdf

Next, be sure of correct coding. You can find a code for facet syndrome (724.8) that may more appropriately describe the condition being diagnosed in the example given.

From a diagnosis coding perspective, the physician's clinical judgment that a diagnosis is appropriate is sufficient for code assignment. For example, when a physician knows that many patient's in the area have a certain type of influenza, it is not necessary to have positive laboratory testing to support reporting the diagnosis code for the diagnosis. This does not however exclude a payer from denying a claim if the payer's policy has requirements that are not met (eg, x-ray evidence of a specified condition).

Hope that helps.