Choosing primary DX - How to determine

Determining the Appropriate Primary ICD-9-CM Diagnosis Code for Diagnostic
Tests Ordered Due to Signs and/or Symptoms


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 Computed
Tomography (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 a 3 cm peripheral
pulmonary nodule. The radiologist should report a diagnosis of
“pulmonary nodule” and may sequence “cough” as an additional
diagnosis.



* Signs or Symptoms:

If the diagnostic test did not provide a definitive 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 emergency room 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.




* Diagnosis Preceded by Words That Indicate Uncertainty:

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:
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).


Test Orders
The referring physician is required to provide diagnostic information to the testing entity at the time the test is ordered. The physician who is treating the patient must order all diagnostic tests.

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 written document signed by the treating physician/practitioner, which is hand-
delivered, mailed or faxed to the testing facility.

*  A telephone call by the treating physician/practitioner or his office to the testing facility. Note: If the order is communicated via telephone, both the treating physician/practitioner or his office and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.
Or,

*  An electronic mail by the treating physician/practitioner or his office to the testing facility.

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.

Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms
When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, the testing facility or the physician interpreting the diagnostic test should report the screening code as the primary diagnosis code. Any condition discovered during the screening should be reported as a secondary diagnosis.

Requirements That Certain Tests Must Be Ordered by the Treating Physician
Internet-Only Manual (IOM) 100-08, Chapter 3, Section 3.4.1.1D

All diagnostic X-ray services, diagnostic laboratory services and other diagnostic
services must be ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem.

1 comment:

Anonymous said...

Is there a list for 2013 or 2012 of the non-billable V codesnot to be used as Primary for Medicare?

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