Unconfirmed diagnoses; consult codes for pre-op visits
Answers to your questions about . . .
Q: If lab or imaging data don't support a particular diagnosis, should I report the presenting symptom and/or sign? For example, a patient complains of fatigue and shortness of breath. Should I assign the original diagnosis "fatigue" until lab and/or other data confirm a diagnosis of anemia? Or, because I suspect anemia, should I report the disease?
A: Without confirmed lab results, you should report the patient's presenting sign and/or symptom.
ICD-9-CM coding guidelines specifically disallow reporting unconfirmed diagnoses, so don't code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working." Rather, "The condition(s) should be coded to the highest degree of certainty for the encounter, such as describing symptoms, signs, abnormal test results, or other reasons for the encounter."
For instance, suppose in the suspected anemia example, you take an expanded problem-focused history, do an expanded problem-focused exam, and those involve low-complexity medical decision-making. You order a complete blood count (CBC).
Until the lab results confirm that the patient has anemia (such as 285.9, anemia, unspecified), report the signs and symptoms for the visitshortness of breath (786.05) and fatigue (780.79). Link 786.05 to the office visit (99213, office or other outpatient visit for the E&M of an established patient . . .). Use 780.79 as the reason for the CBC (85025, blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count; or 85027, blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count]).
Q:A Medicare patient is going in for surgery, and the surgeon requested that the patient see me to have a preoperative history and physical. Which diagnosis and procedure codes should I use?
A: The surgeon is seeking your opinion on the patient's fitness for surgery. If you document the request in the medical record and provide a written report to the requesting surgeon, you can use a consultation code. If the service is done in your office, use an office consultation code (99241-99245); if it's provided in the hospital, use an initial inpatient consultation code (99251-99255).
If the service doesn't meet the definition of a consultation, use another appropriate E&M code, such as 99201-99215. Such nonglobal pre-op exams are payable as long as they're medically necessary and meet the documentation and other requirements for the service billed.
In either case, use the appropriate ICD-9-CM codeV72.81-V72.84for a pre-op examination. Use the codes that describe the patient's underlying condition, such as hypertension or diabetes, and document the appropriate diagnosis code for the condition that prompted surgery.
For more information on Medicare's policy regarding pre-op services, see section 15047 of the Medicare Carriers Manual online at cms.hhs.gov/manuals/14_car/3b15000.asp #_15047_0 .
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Coding Consult: Answers to your questions about. . ..
Dec. 19, 2003;80:17.