Action Alert – CMS Clarifies Diagnosis Coding for Diagnostic Tests

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Action Alerts — Cardiovascular

CMS Clarifies Diagnosis Coding for Diagnostic Tests

The news on the reimbursement front continues to be dismal for cardiovascular medicine.  Physicians will be paid far less than originally expected due to changes announced on November 1, 2001 for the same services under the 2002 Medicare Fee Schedule, and this unexpected change undoubtedly has many physicians and practice managers extremely disturbed and concerned.  In the darkness of these changes comes a small light in that diagnosis coding for cardiovascular diagnostic testing has been formally clarified.  The clarifications will make coding for cardiovascular diagnostic tests much easier.  The following brief from the American College of Cardiology explains the changes that have been made to policies concerning diagnoses for these tests.   Please pass this information along to your physicians and their respective practice administrators.

CMS Clarifies Diagnosis Coding for Outpatient Diagnostic Tests

Good News for Cardiologists  

After years of allowing carriers to implement diverse policies regarding ICD-9 coding for outpatient diagnostic tests, the Centers for Medicare and Medicaid Services (CMS) issued on Sept. 26, 2001, a carrier program memorandum (transmittal B-01-61) outlining a nationally accepted diagnosis coding policy. The new policy is to take effect Jan. 1, 2002.

The memorandum states that the CMS agrees with ICD-9-CM Coding Guidelines for Outpatient Services, which part of the Official ICD-9-CM Guidelines for Coding and Reporting. Via the memorandum, the CMS instructs to report diagnoses for outpatient diagnostic tests based test results after Jan. 1, 2002. This policy contradicts of many former carriers, wherein providers were instructed report only the reason that the outpatient diagnostic was ordered, regardless of the results or findings of a test. Cardiologists have experienced many denials cardiology-related outpatient diagnostic tests due to local carrier policies.

The memorandum, which is accompanied by several examples, explains how to determine the appropriate primary ICD-9-CM diagnosis code for ordered diagnostic tests. For example:

  • If a physician has confirmed a diagnosis based on results of the diagnostic test, then the physician interpreting the test should code that diagnosis. Signs or symptoms that necessitated the test can be reported as additional diagnoses if they are not explained or related to the confirmed diagnosis.
  • If the results of the diagnostic test are normal or do not provide a specific diagnosis, then the interpreting physician should code the signs or symptoms that prompted the treating physician to order the test.
  • If the results of the diagnostic test are normal and the referring physician has recorded a diagnosis that indicates uncertainty, such as “probable”, “suspected”, or “rule out”, then the interpreting physician should not code the referring diagnosis. In this case, the interpreting physician should report the sign or symptom that prompted the test. Diagnoses that are uncertain or unconfirmed should not be reported.

To indicate the reason for the test, the memorandum instructs that referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered and that all diagnostic tests must be ordered by the physician who is treating the beneficiary. The Medicare Carriers’ Manual defines an “order” communication from the treating physician requesting that a diagnostic test be performed. An order for a diagnostic test can be written or delivered by telephone; however, the memorandum states, “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.”

When a diagnostic test is ordered in the absence of any signs or symptoms, the interpreting physician should then report the reason for the test, such as screening. In this case, the physician would use the screening ICD-9, or V, code as the primary ICD-9-CM code. The results of the test may be recorded as additional diagnoses. The memorandum also reminds physicians that incidental findings should never be listed as primary diagnoses. The physician interpreting the test may report these findings as secondary diagnoses. Also, the interpreting physician may report unrelated/co-existing conditions/diagnoses as additional diagnoses.

Physicians are reminded to select the ICD-9-CM code that provides the highest degree of specificity (accuracy and completeness) for the diagnosis resulting from test or for the sign(s)/symptom(s) that prompted the test. The “highest degree of specificity” is defined as assigning the most precise ICD-9-CM code that most fully explains the narrative description of the symptom or diagnosis.

Although this memorandum seems to address many coding problems and subsequent denials, coding consultants are warning coders to read the new policy carefully and to bear the following in mind:

  • For tests ordered as screening exams, one cannot the outcome of the test as the final diagnosis; the screening ICD-9, or V, code should be used;
  • It is not appropriate to code “probable”, “suspected”, or “rule-out” diagnoses based on results that are pending;
  • Even though physicians can now justify tests based on the resulting diagnosis, some carriers’ systems may still “kick out” the final diagnosis because it conflicts with the signs and symptoms that initially made the test medically necessary;
  • When a final diagnosis does not justify the test, the physician must be careful to include pertinent signs or symptoms that prompted the ordering of the test and must report these as additional diagnoses, particularly if they are not fully explained or related to the confirmed diagnosis.

A copy of the program memorandum transmittal B-01-61 can be obtained from the CMS Web site.