July 14, 2008
Know Your ICD-9-CM Guidelines
By Sheri Poe Bernard, CPC, CPC-H, CPC-P
Vol. 9 No. 14 P. 10
Diagnostic codes are relied on to show medical necessity, which is the crux of reimbursement, so proper coding is essential. But diagnostic coding can be a headache for radiology practices.
Additionally, ICD-9-CM coding is not always straightforward. Guidelines do not always appear directly with the codes themselves, and knowing the issues important to radiology is critical. The following are the top 10 coding guidelines regarding radiology diagnostic coding from the federal government’s official ICD-9-CM coding guidelines.
1. Signs and symptoms are acceptable diagnoses when a diagnosis is not confirmed. For example, if a patient is sent to a radiologist to rule out an ankle fracture and no fracture is found, medical necessity is nonetheless established if pain and swelling of the ankle are documented and coded. ICD-9-CM developers created the symptoms, signs, and ill-defined conditions chapter to handle situations in which a suspected illness is ruled out, but symptom codes appear in specific chapters as well. In the case of a ruled-out ankle fracture, the appropriate diagnostic codes would be found in the musculoskeletal chapter—719.07, Effusion of ankle and foot joint. The notes under this code state “Swelling of joint, with or without pain,” so a separate pain code would not be required.
2. Abnormal test results are acceptable diagnoses when further tests are negative. An abnormal blood test or x-ray may lead a provider to order a more complex test. When this occurs and the more extensive test is negative, the earlier positive test result can be listed as the primary diagnosis to establish the medical necessity of the follow-up exam. For example, an ultrasound shows an anomaly in the gastrointestinal tract of a patient, but the follow-up MRI is negative. The primary diagnosis for the MRI would be 793.4, Nonspecific abnormal findings on radiological or other examination of gastrointestinal tract.
3. When a patient encounter is for radiation therapy, be sure to sequence the diagnoses correctly. The guidelines tell us that if the encounter is solely for radiation therapy, the correct primary diagnosis is V58.0, Encounter for radiotherapy. If the treatment causes side effects, they are reported secondarily. If the patient encounter includes a procedure to determine the extent of a malignancy or to excise it, the malignancy is designated as the primary diagnosis and any radiation therapy occurring during the same encounter is reported secondarily.
4. Use combination fracture codes only as a last resort. Fractures of specified sites are coded individually by site. Combined fracture codes (eg, 819, Multiple fractures involving both upper limbs and upper limb with rib[s] and sternum) are for use in triage for multiple trauma, with the expectation that the patient was transferred before definitive diagnoses could be made or when the reporting limits the number of codes that can be listed. Multiple fractures to the same limb, classifiable to the same code, would be reported with a single code. Bilateral fractures are reported separately. Also, sequence fractures in the order of severity, with the most severe fracture listed first.
5. Use screening codes appropriately. In the screening process, an individual with no symptoms is tested for early detection and treatment of a disease. The testing to rule out or confirm a suspected diagnosis is a diagnostic exam, not a screening.
If a condition is discovered in a screening exam, the V code for the screening exam remains the primary diagnosis because the reason for the encounter is the screening. The newly discovered condition is reported secondarily.
6. Report primary treatment of secondary neoplasm sites. When metastasis has occurred and radiation treatment is directed at a secondary neoplasm site, the code for the secondary neoplasm is listed before the code for the primary neoplasm because it is the reason for the encounter.
7. Report a CVA or stroke accurately. The terms stroke and cerebrovascular accident (CVA) are often used interchangeably for cerebral infarct. CVA, stroke, and infarct are all indexed in ICD-9-CM to 434.91, Cerebral artery occlusion, unspecified, with cerebral infarction. Do not report a CVA or stroke with 436, Acute but ill-defined cerebrovascular disease. A postoperative CVA is reported with 997.02, Iatrogenic cerebrovascular infarction or hemorrhage.
8. Code the confirmed diagnosis. When the diagnostic tests have been interpreted by the radiologist and a diagnosis has been confirmed, report this diagnosis. Do not code related signs and symptoms as an additional diagnosis. Chronic diseases that have been documented and are pertinent to the diagnosis or treatment can be coded secondarily.
9. Report E codes as appropriate. E codes establish the circumstances under which an injury occurred and can speed reimbursement by ensuring the right payer gets the information first. For example, ruled-out ankle fracture services would be paid according to whether the injury occurred at work, in a car accident, or during a team sporting event. The right E code directs payment toward the correct insurance provider. If this information is not provided by the referring physician, query the patient and ensure that this information becomes part of the medical record.
10. Know what needs to be documented. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved.
Combined with the information provided in local and national coverage decisions regarding medical necessity, use of the official ICD-9-CM coding guidelines can greatly enhance the ability to document and code diagnoses correctly. Nearly all coding books have the guidelines within them, but be aware that these guidelines are published in October, while the books are published in August. This means that you will need to access the new guidelines each fall to see if any significant changes have been made to them and then note them. The new guidelines are available here.
— Sheri Poe Bernard, CPC, CPC-H, CPC-P, is vice president of member relations at the American Academy of Professional Coders (AAPC), the nation’s largest education and credentialing association for medical coders. The AAPC provides certified credentials to medical coders in physician offices, hospitals, and outpatient centers. The three certifications AAPC offers are Certified Professional Coder (CPC) for physician practices, CPC-H, for hospital coders, and CPC-P for payer organizations.