Diagnosis coding for diagnostic services

Good Morning

Which is correct, choosing a diagnosis code based on reason the test was ordered, or choosing a diagnosis code based on the result of the test, or both?

For example, an EKG was ordered as a pre-op screening before cataract surgery, but a right bundle branch block was discovered. What diagnosis code would you choose to submit with the claim for the EKG?

Thanks

Beth

Beth Aldridge, CPC
Coding Manager

Northern California Medical Associates, Inc
Phone: (707) 573-6145
Fax: (707) 573-6932

Comments

  • You must use the preop screening code and if the surgery planned was
    listed, this would be second.
    If no reason for surgery listed , then this would be a noncovered preop
    exam. If you have reason for surgery list this second and then third you
    can list the findings.

    THis is part of Official Coding Guidelines and is import to follow these
    rules.

    Just to let you know, any exam done as screening, you put screening code
    prime no matter the findings.

    Sharon Cohen


  • That’s what I thought but I am getting pushback.

    Beth Aldridge, CPC
    Coding Manager

    Northern California Medical Associates, Inc
    Phone: (707) 573-6145
    Fax: (707) 573-6932

  • Except for Medicare colonoscopies that turned from screening to diagnostic! ☺

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • Beth
    I did think thought that on certain procedures you can code the findings, Radiology may be one but not sure about the medicine section codes

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • According to Pub 100-04, Medicare Claims Processing Manual, Chapter 13, Section 10 - ICD Coding for Diagnostic Tests, for outpatient and provider office services it's based on the results. It reads:

    "10 - ICD Coding for Diagnostic Tests (Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: June 11, 2013, ICD-10: Upon Implementation of ICD-10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared System Edits; July 7, 2014 - CWF development/testing, FISS requirement development; October 6, 2014 - CWF, FISS, MCS Shared System Edits), ICD-10: Upon Implementation of ICD-10)

    The ICD Coding Guidelines for Outpatient Services (hospital-based and physician office) have instructed physicians to report diagnoses based on test results. Instructions and examples for coding specialists, contractors, physicians, hospitals, and other health care providers to use in determining the use of ICD codes for coding diagnostic test results is found in chapter 23."

    This may be found at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf

    You'll want to also see ch. 23 of Pub 100-04, section 10: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf



    Kris

    Kris Cuddy, CPC, CIMC
    Healthcare Compliance Analyst
    Compliance Office
    Michigan State University HealthTeam
    East Lansing, MI
    Ofc: 517-355-4547
    Fax: 517-353-5292

  • Let me clarify this answer is for Medicare Beneficiaries.

    Kris

    Kris Cuddy, CPC, CIMC
    Healthcare Compliance Analyst
    Compliance Office
    Michigan State University HealthTeam
    East Lansing, MI
    Ofc: 517-355-4547
    Fax: 517-353-5292

    From: Kristine Cuddy
    Sent: Tuesday, January 24, 2017 2:48 PM
    To: Multiple recipients of list PARTB-L
    Subject: RE:[partb-l] Diagnosis coding for diagnostic services

    According to Pub 100-04, Medicare Claims Processing Manual, Chapter 13, Section 10 - ICD Coding for Diagnostic Tests, for outpatient and provider office services it's based on the results. It reads:

    "10 - ICD Coding for Diagnostic Tests (Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: June 11, 2013, ICD-10: Upon Implementation of ICD-10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared System Edits; July 7, 2014 - CWF development/testing, FISS requirement development; October 6, 2014 - CWF, FISS, MCS Shared System Edits), ICD-10: Upon Implementation of ICD-10)

    The ICD Coding Guidelines for Outpatient Services (hospital-based and physician office) have instructed physicians to report diagnoses based on test results. Instructions and examples for coding specialists, contractors, physicians, hospitals, and other health care providers to use in determining the use of ICD codes for coding diagnostic test results is found in chapter 23."

    This may be found at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf

    You'll want to also see ch. 23 of Pub 100-04, section 10: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf



    Kris

    Kris Cuddy, CPC, CIMC
    Healthcare Compliance Analyst
    Compliance Office
    Michigan State University HealthTeam
    East Lansing, MI
    Ofc: 517-355-4547
    Fax: 517-353-5292


  • I think this is where we have a lot of issues though

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • Yes, if the results are related to the indication. When the indication is
    screening with no symptoms, then the primary code is screening. As I
    mentioned in my last email see the Official Coding Guidelines.See Chapter 21
    -5. You are taking a risk if you code a screening exam with findings of the
    report prime.
    Sharon Cohen, RHIA,MSM


  • Is your lab an outpatient?

    Here's ICD-10 CDC Coding Guidelines:

    "K. Patients receiving diagnostic services only For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.

    For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test.

    For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

    Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results."

    Found at: https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf

    Kris

    Kris Cuddy, CPC, CIMC
    Healthcare Compliance Analyst
    Compliance Office
    Michigan State University HealthTeam
    East Lansing, MI
    Ofc: 517-355-4547
    Fax: 517-353-5292

  • Yes!

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • These are published by CMS/ Medicare which they tend to create their own guidelines so I think possibly would override the official Coding Guidelines. I read it as only what is intended for these specifics not all and every service.

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • these are published in the front of the ICD 10 book so I am quite sure this
    guideline applies to all coding.
    If patient has no symptoms or diagnosis , this is an exam perhaps with no
    medical necessity . Only certain screenings are covered not all.




  • Your diagnosis code is based on the signs, symptoms or diagnosis that was
    provided as the *reason* for the exam/procedure. A patient may present with
    abdominal pain and after testing the gall bladder seems to be the problem.
    That, however, is a decision made by the provider *after *the procedure.

    E. D. Wade, RN, RHIA

  • Marie Cohen’s responses were right on target. This is a screening test (not diagnostic as indicated in the subject line), and must be coded using those rules.

    First, there must be a distinction made between:

    · Screening tests, for which no sign/symptom exists, and the provider is looking for the presence of a condition; and

    · Diagnostic tests, for which a sign/symptom exists and which aims to identify the condition causing the signs/symptoms.

    The reporting rules are different depending on which type of test it is. Some of the responses-to/disagreements-with Marie’s correct responses mention the rules for diagnostic tests, which rules again are different from and completely irrelevant for discussing how to code for screening tests.

    To summarize:

    · ICD-10-CM instructs that a “screening” dx be used first for all screening tests, and IF a condition is found it is listed “as an additional diagnosis.” For pre-op screenings, the diagnosis for the condition prompting the surgery goes in-between. Also, this rule is not altered for screening colonoscopies which evolve into “therapeutic” procedures because of the removal of polyps. The CPT/procedure code changes in these instances, but the diagnosis code reporting still lists the screening code first since that’s the way it started. Polyps are listed as an additional diagnosis. Medicare does not disagree with this.

    · ICD-10-CM instructs that diagnostic tests be coded with the definitive diagnosis for the actual condition instead of the original sign/symptom when such a diagnosis can be made by the end of the service. A diagnosis for the original sign/symptom can be used if no definitive diagnosis was arrived at by the end of the service. Medicare does not disagree with this.

    Seth Canterbury, CPC, CPC-I
    Clinical Data Quality Education Department
    University of Florida Jacksonville Physicians, Inc.
    653 West Eighth Street
    Tower I, Suite 606
    Jacksonville, FL 32209
    (202) 642-1105



  • I’m so impressed with your response. It’s very clear and it also acknowledges previous responses. Most of all, it’s accurate. Thank you!

    Kathy Olson, BA, CPC

  • HI Seth
    So how do you handle those that are pre-operative screenings and they have a finding, wouldn’t it be relevant to risk I mean for pre-operative EKG I would just put both, but for other tests, for example when we are doing a screening colonoscopy (and I’m talking our MAC here) they advise, that if it’s a screening which turns into a finding you are to report it as a diagnostic service append the PT modifier and code to the finding first listed Diagnosis not the screening and then the finding, they deny them if you submit them that way and they post MEDLEARN matters memorandum advising how to bill for this service. There are no indications until they get in there and remove the polyp. That doesn’t seem to fit into the official guidelines.

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • Our MAC (noridian) does not take this stance. They had MED LEARN MATTERS article on this subject a year or two ago and they want the finding first, if you bill the diagnostic colonoscopy with the screening in first position it denies as PR49 patient responsibility. (in reference to screening colonoscopies) I have had to correct many based on their guideline. Am I going to bill the patient for this service because I put the screening diagnosis first. And then the finding based on the ICD10 official guidelines or do I appeal to them on this subject matter?

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • Karyn,

    Here is the latest article from CMS on this I have: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se0746.pdf.

    From p.2 of that article:

    A patient presents for a screening colonoscopy (or flexible sigmoidoscopy), and the patient has no gastrointestinal symptoms. During the subsequent screening colonoscopy (or flexible sigmoidoscopy), an abnormality is identified (such as a polyp, etc.), and it is biopsied or removed.

    CMS advises that, whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-9 code for the screening examination.

    As an example, the above scenario should be billed as follows using claim form CMS-1500 (or its electronic equivalent):

    · Item 21 (Diagnosis or Nature of Illness or Injury)

    • Indicate the Primary Diagnosis using the International Classification of Diseases, Ninth Revision, Clinical Modification, (ICD-9-CM) code for the screening examination (colonoscopy or sigmoidoscopy), and

    • Indicate the Secondary Diagnosis using the ICD-9-CM code for the abnormal finding (polyp, etc.).

    For example, V76.51 (Special screening for malignant neoplasms, Colon) would be used as the first listed code, while the secondary code might be 211.3 (Benign neoplasm of other parts of digestive system, Colon).

    Again, this just pertains to diagnosis code reporting. Procedure code reporting does indeed change if polyps are found and excised.

    Please let me know if you have something published after this that shows they reversed course.

    Seth


  • So interesting! I am going to try this out and if they deny it as PR49 I will use this article, they need to fix their system, for example when we bill a screening colonoscopy (true screening) the drugs they deny as PR49 (patient responsibility) the denial states that they are not covered when considered routine! We are billing for two J codes, versed and another one, Now I have been advised by them that the drugs are included with the procedure but that is not how the denial comes across so we adjust them off as to not bill the patient this amount! I will see what I have saved
    Thanks, Karyn

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • edited May 2017
    Are you providing moderate sedation or just anxiolysis? Anesthesia (drugs) other than moderate sedation would be included.

  • Hi Seth
    I did an experiment on this, I just had two claims come back denied for screening turned diagnostic where the screening code was in the primary position it had the PT modifier and the procedure was 45380- They both denied PR49 to patient responsibility. So we are now fixing them. I guess Noridian doesn’t follow along…?


    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

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