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Outpatient Registration: Accurate Coding Begins With Proper ICD-9 Assignment

Signs and symptoms are the way to go when a diagnosis isn鈥檛 certain

Although ICD-9 coding does not directly affect hospital outpatient reimbursement, Medicare and other payers still require that you show medical necessity for services rendered. In other words, appropriate diagnoses must support all of your CPT code selections (and, in turn, the APC categories under which Medicare pays your facility).
In an outpatient setting, however, the physician has not always established a definitive diagnosis for the patient prior to registration. The solution? Rely on the patient鈥檚 signs and symptoms to justify the outpatient visit.


Inpatient 鈥楻ule Outs鈥� Break Outpatient Rules

Physicians in an inpatient setting may order diagnostic tests or other services to 鈥渞ule out鈥� a suspected condition, but the same rules do not apply in the outpatient setting. ICD-9 coding guidelines Section I B. 6. and Section IV. E. state, 鈥淐odes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.鈥�
Watch for: Keep an eye out for any of the following phrases in your provider鈥檚 documentation: 鈥減robable,鈥� 鈥渟uspected,鈥� 鈥渓ikely,鈥� 鈥渜uestionable,鈥� 鈥減ossible,鈥� and 鈥渟till to be determined.鈥� These indicate that the provider has not formally diagnosed the patient with the condition or disease.
By reporting the signs and symptoms that prompted the physician to initiate the outpatient encounter rather than a suspected, but unconfirmed, condition, you avoid labeling the patient with an uncertain diagnosis while still allowing for reimbursement.
For example, if the patient visits the outpatient department for testing to rule out a myocardial infarction, and the tests return negative, you will have nothing left to code for. If the physician provides the signs and symptoms that prompted the test (chest pain, etc.), however, you鈥檒l have ICD-9 codes to support the services your facility provided.
Tip: To aid in selecting diagnoses for hospital outpatient encounters, consider using a physician order form that specifically asks the physician to identify the signs and symptoms prompting the encounter, such as the sample at right.


Confirmation Calls for Definitive Dx

If the physician confirms a diagnosis via testing or pathology, for instance, you should report the definitive diagnosis instead of the signs or symptoms that prompted the procedure, according to CMS program memorandum AB-01-144 (Sept. 26, 2001).
Example: A gastroenterologist schedules a patient for an outpatient encounter to test for Crohn鈥檚 disease (555.9). Unless and until testing or other diagnostic services confirm the Crohn鈥檚 diagnosis, however, you should rely on signs and symptoms to justify medical necessity for any [...]

- Published on 2007-08-24