Determining the Appropriate Primary ICD-9-CM Diagnosis Code for Diagnostic Tests Ordered Due to Signs and/or Symptoms
A. Confirmed Diagnosis Based on Results of Test
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.”
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.”
Signs or Symptoms
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.
C. Diagnosis Preceded by Words that Indicate Uncertainty
If the results of the diagnostic test are normal or nondiagnostic and the referring physician records a diagnosis preceded by words that indicate uncertainty (e.g., probably, 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).
