From the Medicare Carrier's Manual - http://www.cms.hhs.gov/manuals/cmsindex.asp

Franklin W. West
PVI
(425) 398-7774 (Office)
(425) 486-8976 (fax)
www.PacificVascular.com
www.PVICME.com
 
15021.1 ICD-9-CM Coding for Diagnostic Tests.--
As required by the Health Insurance Portability and Accountability Act (HIPAA), the Secretary published a rule designating the ICD-9-CM and its Official ICD-9-CM Guidelines for Coding and Reporting as one of the approved code sets for use in reporting diagnoses and inpatient procedures.  This final rule requires the use of ICD-9-CM and its official coding and reporting guidelines by most health plans (including Medicare) by October 16, 2002. The Administrative Simplification Act of 2001, however, permits plans and providers to apply for an extension until October 16, 2003. HHS anticipates that most plans and providers will obtain this extension.
The Official ICD-9-CM Guidelines for Coding and Reporting provides guidance on coding. The ICD-9-CM Coding Guidelines for Outpatient Services, which is part of the Official ICD-9-CM Guidelines for Coding and Reporting, provides guidance on diagnosis coding specific to outpatient facilities and physician offices.
The ICD-9-CM Coding Guidelines for Outpatient Services (hospital-based and physician office) have instructed physicians to report diagnoses based on test results. The Coding Clinic for ICD-9- CM confirms this longstanding coding guideline. CMS conforms with these longstanding official coding and reporting guidelines.
The following are instructions and examples for coding specialists, contractors, physicians, hospitals, and other health care providers to use in determining the use of ICD-9-CM codes for coding diagnostic test results. The instructions below provide guidance on the appropriate assignment of ICD-9-CM diagnosis codes to simplify coding for diagnostic tests consistent with the ICD-9-CM Guidelines for Outpatient Services (hospital-based and physician office). Note that physicians are responsible for the accuracy of the information submitted on a bill.
Additional examples of using ICD-9-CM codes consistently with ICD-9-CM Coding Guidelines for Outpatient Services are provided at the end of this section.
A. Determining the Appropriate Primary ICD-9-CM Diagnosis Code For Diagnostic Tests Ordered Due to Signs and/or Symptoms.--
1. 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 related to the confirmed diagnosis.
EXAMPLE 1: A surgical specimen is sent to a pathologist with a diagnosis of "mole." The pathologist personally reviews the slides made from the specimen and makes a diagnosis of "malignant melanoma". The pathologist should report a diagnosis of "malignant melanoma" as the primary diagnosis.
EXAMPLE 2: A patient is referred to a radiologist for an abdominal CT scan with a diagnosis of abdominal pain. The CT scan reveals the presence of an abscess. The radiologist should report a diagnosis of "intra-abdominal abscess."
EXAMPLE 3: A patient is referred to a radiologist for a chest x-ray with a diagnosis of "cough". The chest x-ray reveals a 3 cm peripheral pulmonary nodule. The radiologist should report a diagnosis of "pulmonary nodule" and may sequence "cough" as an additional diagnosis.
2. If the diagnostic test did not provide a definitive diagnosis or was normal, the testing facility or the interpreting physician should code the sign(s) or symptom(s) that prompted the treating physician to order the study.
EXAMPLE 1: A patient is referred to a radiologist for a spine x-ray due to complaints of "back pain". The radiologist performs the x-ray, and the results are normal. The radiologist should report a diagnosis of "back pain" since this was the reason for performing the spine x-ray.
EXAMPLE 2: A patient is seen in the ER for chest pain. An EKG is normal, and the final diagnosis is chest pain due to suspected gastroesophageal reflux disease (GERD). The patient was told to follow-up with his primary care physician for further evaluation of the suspected GERD. The primary diagnosis code for the EKG should be chest pain. Although the EKG was normal, a definitive cause for the chest pain was not determined.
3. 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 referring diagnosis. Rather, the interpreting physician should report the sign(s) or symptom(s) that prompted the study. Diagnoses labeled as uncertain are considered by the ICD-9-CM Coding Guidelines as unconfirmed and should not be reported. This is consistent with the requirement to code the diagnosis to the highest degree of certainty.
EXAMPLE: A patient is referred to a radiologist for a chest x-ray with a diagnosis of "rule out pneumonia." The radiologist performs a chest x-ray, and the results are normal. The radiologist should report the sign(s) or symptom(s) that prompted the test (e.g., cough).
B. Instruction to Determine the Reason for the Test.--As specified in §4317(b) of the Balanced Budget Act (BBA), referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered. As indicated in MCM §15021, the treating physician/practitioner must order all diagnostic tests furnished to a beneficiary who is not an institutional inpatient or outpatient. As further defined in §15021 of this manual, an "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. Section 15021 provides a definition of an "order." Note if the order is communicated via telephone, both the treating physician/practitioner or his/her office and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records.
1. On the rare occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient's medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.
EXAMPLE: A patient is referred to a radiologist for a gastrograffin enema to rule out appendicitis. However, the referring physician does not provide the reason for the referral and is unavailable at the time of the study. The patient is queried and indicates that he/she saw the physician for abdominal pain, and was referred to rule out appendicitis. The radiologist performs the x- ray, and the results are normal. The radiologist should report the abdominal pain as the primary diagnosis.
2. In the event the physician's interpretation of the test result is not clear or ambiguously stated in the patient's medical record, contact either the attending physician or the physician that performed the test for clarification. This may result in the reporting of symptoms or a confirmed diagnosis.
3. If the test (i.e., lab test) has been performed and the results are back, but the patient's physician has not yet reviewed them to make a diagnosis, or there is no physician interpretation, then code the symptom or the diagnosis provided by the referring physician.
4. In the event the individual responsible for reporting the codes for the testing facility or the physician's office does not have the report of the physician interpretation at the time of billing, the individual responsible for reporting the codes for the testing facility or the physician's office should code what they know at the time of billing. Sometimes reports of the physician's interpretation of diagnostic tests may not be available until several days later, which could result in delay of billing.  Therefore, in such instances, the individual responsible for reporting the codes for the testing facility or the physician's office should code based on the information/reports available to them, or what they know, at the time of billing.
C. Incidental Findings.--Incidental findings should never be listed as primary diagnoses. If reported, incidental findings may be reported as secondary diagnoses by the physician interpreting the diagnostic test
EXAMPLE 1: A patient is referred to a radiologist for an abdominal ultrasound due to jaundice. After review of the ultrasound, the interpreting physician discovers that the patient has an aortic aneurysm. The interpreting physician reports jaundice as the primary diagnosis and may report the aortic aneurysm as a secondary diagnosis because it is an incidental finding.
EXAMPLE 2: A patient is referred to a radiologist for a chest x-ray because of wheezing. The x-ray is normal except for scoliosis and degenerative joint disease of the thoracic spine. The interpreting physician reports wheezing as the primary diagnosis since it was the reason for the patient's visit and may report the other findings (scoliosis and degenerative joint disease of the thoracic spine) as additional diagnoses.
EXAMPLE 3: A patient is referred to a radiologist for a magnetic resonance imaging (MRI) of the lumbar spine with a diagnosis of L-4 radiculopathy. The MRI reveals degenerative joint disease at L1 and L2. The radiologist reports radiculopathy as the primary diagnosis and may report degenerative joint disease of the spine as an additional diagnosis.
D. Unrelated/Co-Existing Conditions/Diagnoses.--Unrelated and co-existing conditions/diagnosis may be reported as additional diagnoses by the physician interpreting the diagnostic test.
EXAMPLE: A patient is referred to a radiologist for a chest x-ray because of a cough. The result of the chest x-ray indicates the patient has pneumonia. During the performance of the diagnostic test, it was determined that the patient has hypertension and diabetes mellitus. The interpreting physician reports a primary diagnosis of pneumonia. The interpreting physician may report the hypertension and diabetes mellitus as secondary diagnoses.
E. Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms (e. g., screening tests).-
When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, the testing facility or the physician interpreting the diagnostic test should report the screening code as the primary diagnosis code. Any condition discovered during the screening should be reported as a secondary diagnosis.
F. Use of ICD-9-CM To The Greatest Degree of Accuracy and Completeness.--
NOTE: This section explains certain coding guidelines that address diagnosis coding. These guidelines are longstanding coding guidelines that have been part of the Official ICD-9-CM Guidelines for Coding and Reporting.
The testing facility or the interpreting physician should code the ICD-9-CM code that provides the highest degree of accuracy and completeness for the diagnosis resulting from the test, or for the sign(s)/symptom(s) that prompted the ordering of the test.
In the past, there has been some confusion about the meaning of "highest degree of specificity," and "reporting the correct number of digits." In the context of ICD-9-CM coding, the "highest degree of specificity" refers to assigning the most precise ICD-9-CM code that most fully explains the narrative description in the medical chart of the symptom or diagnosis.
EXAMPLE 1: A chest x-ray reveals a primary lung cancer in the left lower lobe. The interpreting physician should report the ICD-9-CM code as 162.5 for malignancy of the "left lower lobe, bronchus or lung", not the code for a malignancy of "other parts of bronchus or lung" (162.8) or the code for "bronchus and lung unspecified" (162.9).
EXAMPLE 2: If a sputum specimen is sent to a pathologist and the pathologist confirms growth of "streptococcus, type B" which is indicated in the patient's medical record, the pathologist should report a primary diagnosis as 482.32 (Pneumonia due to streptococcus, Group B). However, if the pathologist is unable to specify the organism, then the pathologist should report the primary diagnosis as 486 (Pneumonia, organism unspecified).
In order to report the correct number of digits when using ICD-9-CM, refer to the following instructions:
ICD-9-CM diagnosis codes are composed of codes with 3, 4, or 5 digits. Codes with 3 digits are included in ICD-9-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits to provide greater specificity. Assign three-digit codes only if there are no four-digit codes within that code category. Assign four-digit codes only if there is no fifth-digit subclassification for that category. Assign the fifth-digit subclassification code for those categories where it exists.
EXAMPLE 3: A patient is referred to a physician with a diagnosis of diabetes mellitus. However, there is no indication that the patient has diabetic complications or that the diabetes is out of control. It would be incorrect to assign code 250 since all codes in this series have 5 digits. Reporting only three digits of a code that has 5 digits would be incorrect. One must add two more digits to make it complete. Because the type (adult onset/juvenile) of diabetes is not specified, and there is no indication that the patient has a complication or that the diabetes is out of control, the correct ICD-9-CM code would be 250.00.  The fourth and fifth digits of the code would vary depending on the specific condition of the patient. One should be guided by the code book.
For the latest ICD-9-CM coding guidelines, please refer to the following Web site:
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm#guide.
Refer to the following questions and answers for further guidance on determining the appropriate ICD-9-CM diagnoses codes. The questions and answers appeared in the American Hospital Association's (AHA) Coding Clinic for ICD-9-CM (1st Qtr 2000).
EXAMPLES:
<SNIP - too many lines>
-----Original Message-----
From: UVM Flownet [mailto:[log in to unmask]] On Behalf Of Jasa, Randy
Sent: Thursday, September 22, 2005 9:58 AM
To: [log in to unmask]
Subject: Indication Versus History
Importance: High

This question may seem pretty basic, but we are making some changes in our labs that brought the issue up and I did not have a good answer.  Our lab is converting over to an electronic reporting format where the sonographer will complete a fairly detailed preliminary report.  As part of the preliminary they will enter the indication for the exam in one field and a patient history in the other field.  The clarification I am seeking is in two parts.  The first is if a patient is sent to me from the ER with the order written "Left Lower Extremity Venous Ultrasound- Rule out DVT", but after talking to the patient I find out the patient has an acute history of unilateral leg swelling and pain, what is the indication for the test?  Is it "rule out DVT" or is it "leg pain and swelling"?   
 
The second part of the test is related to coding.  If I assume that the indication for the test is "rule out DVT", but in the history I list pain and swelling, how is that to be coded?  Can the test be coded from the history or only from the indication?  We have no involvement in the coding process.  I am just curious about that part. 
 
I would appreciate advice on these issues.  I am sure they are not completely uncommon.  The best solution would be to have the doctors write the order with the correct diagnosis in the first place.  Something we are striving for, but have not yet achieved.
 
Thanks
 
Randy Jasa BS, RVT
Ultrasound Supervisor
Cardiovascular Services
Lee Memorial Health System
Cape Coral, FL

CONFIDENTIALITY NOTICE: The information contained in this email, including any attachments, is private, confidential and protected from disclosure.  If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any unauthorized review, disclosure or distribution is strictly prohibited.  If you have received this communication in error, please notify us immediately by replying to the message and deleting it from your computer.  Thank you.  Pacific Vascular, Inc.

To unsubscribe or search other topics on UVM Flownet link to:
http://list.uvm.edu/archives/uvmflownet.html