Program Memorandum to the Intermediaries/Carriers Centers for
Medicare & Medicaid Services (CMS)
SUBJECT:
ICD-9-CM Coding for Diagnostic Tests
Coding to the highest level of specificity: This
Program Memorandum (PM) clarifies the current coding
guidelines for reporting diagnostic tests. Specifically,
this PM clarifies the reporting of the International
Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM) codes 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
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 diagnoses coding
specifically for 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 agrees with these
long standing official coding and reporting guidelines. Following
are instructions for 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 diagnoses 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. A.
Determining the Appropriate Primary ICD-9-CM Diagnosis
Code For Diagnostic Tests Ordered Due to Signs and/or
Symptoms 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 3 cm
peripheral pulmonary nodule. The radiologist should
report a diagnosis of “pulmonary nodule” and may
sequence “cough” as an additional diagnosis. If
the diagnostic test did not provide a diagnosis or was
normal, 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. 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 1: 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). 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 further indicated in 42 CFR 410.32 all
diagnostic tests “must be ordered by the physician who
is treating the beneficiary.” As defined in the
Medicare Carrier Manual (MCM), an “order” is a
communication from the treating physician/practitioner
requesting that a diagnostic test be performed for a
beneficiary. An order may include the following forms of
communication: a.
A written document signed by the treating
physician/practitioner, which is hand delivered, mailed,
or faxed to the testing facility; b.
A telephone call by the treating physician/practitioner
or his/her office to the testing facility; and c.
An electronic mail by the treating
physician/practitioner or his/her office to the testing
facility. 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. 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.
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. Unrelated/Co-Existing
Conditions/Diagnoses
Unrelated
and co-existing conditions/diagnoses 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. 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 physician interpreting the diagnostic test should
report the reason for the test (e. g. screening) as the
primary ICD-9-CM diagnosis code. The results of the
test, if reported, may be recorded as additional
diagnoses. Use of
ICD-9-CM To The Greatest Degree of Accuracy and
Completeness
NOTE:
This section explains certain coding guidelines that
address diagnoses coding. These
guidelines are longstanding coding guidelines that have
been part of the Official ICD-9-CM Guidelines for
Coding and Reporting. The interpreting physician
should code the ICD-9-CM code that provides the highest
degree of accuracy and completeness for the diagnosis
resulting from 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 in
“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 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.
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.
Question 1: A
skin lesion of the cheek is surgically removed and
submitted to the pathologist for analysis. The surgeon
writes on the pathology order, “skin lesion.” The
pathology report comes back with the diagnosis of
“basal cell carcinoma.” A laboratory-billing
consultant is recommending that the ordering
physician’s diagnosis be reported instead of the final
diagnosis obtained by the pathologist. Also, an
insurance carrier is also suggesting this case be coded
to ”skin lesion” since the surgeon did not know the
nature of the lesion at the time the tissue was sent to
pathology. Which code should the pathologist use to
report his claim? Answer 1: The
pathologist is a physician and if a diagnosis is made it
can be coded. It is appropriate for the pathologist to
code what is known at the time of code assignment. For
example, if the pathologist has made a diagnosis of
basal cell carcinoma, assign code 173.3, Other malignant
neoplasm of skin, skin of other and unspecified parts of
face. If the pathologist had not come up with a
definitive diagnosis, it would be appropriate to code
the reason why the specimen was submitted, in this
instance, the skin lesion of the cheek. Question 2: A
patient presents to the hospital for outpatient x-rays
with a diagnosis on the physician’s orders of
questionable stone. The abdominal x-ray diagnosis per
the Radiologist is “bilateral nephrolithiasis with
staghorn calculi.” No other documentation is
available. Is it correct to code this as 592.0, Calculus
of kidney, based on the radiologist’s diagnosis? Answer 2: The
radiologist is a physician and he/she diagnosed the
nephrolithiasis. Therefore, it is appropriate to code
this case as 592.0, Calculus of kidney. Question 3: A
patient undergoes outpatient surgery for removal of a
breast mass. The pre- and post-operative diagnosis is
reported as “breast mass.” The pathological
diagnosis is fibroadenoma. How should the hospital
outpatient coder code this? Previous Coding Clinic advice
has precluded us from assigning codes on the basis of
laboratory findings. Does the same advice apply to
pathological reports? Answer 3: Previously
published advice has warned against coding from
laboratory results alone, without physician
interpretation. However, the pathologist is a physician
and the pathology report serves as the pathologist’s
interpretation and a microscopic confirmatory report
regarding the morphology of the tissue excised.
Therefore, a pathology report provides greater
specificity. Assign code 217, Benign neoplasm of breast,
for the fibroadenoma of the breast. It is appropriate
for coders to code based on the physician documentation
available at the time of code assignment. Question 4: A
referring physician sent a urine specimen to the
cytology lab for analysis with a diagnosis of
”hematuria” (code 599.7). However, a cytology report
authenticated by the pathologist revealed abnormal cells
consistent with transitional cell carcinoma of the
bladder. Although the referring physician assigned code
599.7, Hematuria, the laboratory reported code 188.9,
Malignant neoplasm of bladder, Bladder, part
unspecified. For reporting purposes, what would be the
appropriate diagnosis code for the laboratory and the
referring physician? Answer 4: The
laboratory should report code 188.9, Malignant neoplasm
of bladder, Bladder, part unspecified.It is appropriate
to code the carcinoma, in this instance, because the
cytology report was authenticated by the pathologist and
serves as confirmation of the cell type, similar to a
pathology report. The referring physician should report
code 599.7, Hematuria, if the result of the cytological
analysis is not known at the time of code assignment. Question 5: A
patient presents to the physician’s office with
complaints of urinary frequency and burning. The
physician ordered a urinalysis and the findings were
positive for bacteria and increased WBCs in the urine.
Based on these findings a urine culture was ordered and
was positive for urinary tract infection. Should the lab
report the “definitive diagnosis,” urinary tract
infection, or is it more appropriate for the lab to
report the signs and symptoms when submitting the claim? Answer 5: Since
this test does not have physician interpretation, the
laboratory (independent or hospital-based)should code
the symptoms (i.e., urinary frequency and burning). Question 6: The
physician refers a patient for chest x-ray to outpatient
radiology with a diagnosis of weakness and chronic
myelogenous leukemia (CML). The radiology report
demonstrated no acute disease and moderate hiatal
hernia. For
reporting purposes, which codes are appropriate for the
facility to assign? Answer 6: Assign
code 780.79, Other malaise and fatigue, and code 205.10,
Myeloid leukemia, without mention of remission, for this
encounter. It is not necessary to report code 553.3,
Diaphragmatic hernia, for the hiatal hernia, because it
is an incidental finding. [For
CMS purposes, the primary diagnosis would be reported as
780.79 (Other malaise and fatigue), and the secondary
diagnosis as 205.10 (Myeloid leukemia, without mention
of remission, for this encounter). Question 7: A
patient presents to the doctor’s office with a
complaint of fatigue. The physician orders a complete
blood count (CBC). The CBC reveals a low hemoglobin and
hematocrit. Should the lab report the presenting symptom
fatigue (code 780.79) or the finding of anemia (code
285.9)? Answer 7: The laboratory (independent or hospital-based) should code the symptoms, because no physician has interpreted the results. Assign code 780.79, Other malaise and fatigue, unless the lab calls the physician to confirm the diagnosis of anemia. |
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