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
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
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
Beth Aldridge, CPC
Coding Manager
Northern California Medical Associates, Inc
Phone: (707) 573-6145
Fax: (707) 573-6932
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
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
"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
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
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
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
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
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 Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
AHIMA ICD10 PROFICIENT
Government Reimbursement Analyst-Sharp Health Care
PFS-CCD 3rd Floor
858-499-4382
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.
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
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
Kathy Olson, BA, CPC
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
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
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
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
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