The ongoing controversy over whether to use signs and symptoms or the test result to code a diagnostic test has been resolved for the providers performing the tests radiologists, pathologists, laboratories as well as for urologists when they interpret the test results themselves. In general the physician who orders the test should code the symptom that prompted the test, and the interpreting physician should code the result.
The coding guidelines for outpatient services from ICD-9 instruct interpreting physicians to report diagnoses based on test results, according to the program memorandum issued Sept. 26, 2001 (Transmittal AB-01-144). Referring physicians should code the reason, usually a symptom, for ordering the test. The transmittal notes that CMS agrees with these policies.
The transmittal doesn't specify whether the referring physician has the option of waiting for the test result to come back before coding the claim. However, industry standard has always left the decision on when to bill up to the individual physician, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services in Denver, Colo. "If the referring physician wants to wait for the results of the diagnostic test before billing, no guidelines would prohibit this," says Page. "But unless the referring physician is billing the test there would be no reason to wait for the results."
Interpreting Versus Ordering a Test
If the physician knows the diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis, the transmittal states. Use signs and symptoms as a secondary diagnosis if unrelated to the confirmed diagnosis.
However, the physician who ordered the test should not use the result as the diagnosis code. A physician who interprets a test, whether the physician is the urologist ordering the test or the radiologist or pathologist interpreting it, can make final code assignment. The ordering physician uses the symptom.
For example, a urologist sends a patient for outpatient x-rays with a diagnosis of renal colic (788.0). The x-ray diagnosis per the radiologist is "bilateral nephrolithiasis with staghorn calculi" and the code in this case is 592.0 (calculus of kidney). When the urologist gets the radiologist's report, he or she should code the subsequent visit as 592.0 as well.
If, however, a laboratory technician, and not a physician, performs and interprets the test, code assignment must be restricted to that made by the referring urologist. For example, the urologist sends a urine speci- men to a lab, and puts "hematuria" (599.7) on the order for the diagnostic test. The pathologist then interprets abnormal cells transitional cell carcinoma of the bladder, and should assign 791.7 (nonspecific findings on examination of urine; other [...]