In less than six months, on Oct. 1, 2015, the health industry is changing from ICD-9-CM to ICD-10-CM for diagnosis coding. While most of the coding changes do not directly affect pathology diagnosis practices (e.g., right vs. left breast or initial vs. subsequent encounter for fracture), it is not yet known how well payers will accept “unspecified” code options.

Pathology practices and laboratories can start now to secure a smooth transition from ICD-9 to ICD-10 — and decrease the likelihood of denials — by ensuring they are receiving complete diagnosis information from referring physicians on every case. This may require both enhancement of your lab intake protocols and education of referring physicians/staff to help ensure that the clinical reason for each request is properly and thoroughly documented. 

Diagnosis coding rules for lab tests differ from those for pathology. Because lab tests are not interpreted by the pathologist, they are coded from the referring physician’s reason for ordering the test (including pap smears). Pathologist-interpreted tests are coded from the pathologist’s diagnosis, but not all specimens have pathology.

In these negative-for-pathology cases, the clinician’s reason is again used to obtain the diagnosis code.

Below are the most common scenarios of insufficient diagnosis information on pathology and laboratory cases, and tips on how to address these errors.

  1. No History Provided
    Federal law requires that the referring physician must give the reason for ordering a diagnostic service, and if not provided, the pathologist/lab must request this information. Many lab tests have payment rules related to whether the test is screening vs. diagnostic, and limitations on qualifying (“payable”) diagnoses. Review your requisitions on accessioning to help ensure that the clinician’s reason for request is clear.
  2. Uncertain Diagnosis
    Coders cannot assign diagnoses that are uncertain. Wording such as “suspected,” “suggestive of” or “rule out” does not constitute a definitive diagnosis. If the patient doesn’t yet have a diagnosis, the referring physician should provide the patient’s presenting signs or symptoms that prompted the ordering of the pathology or lab service.
  3. Incomplete, Vague or Irrelevant Clinical History Supplied
    While knowing the procedure that was performed — such as breast biopsy or FNA thyroid — is helpful, this is not sufficient detail from which a diagnosis code can be assigned. And remember, diagnosis codes are used by payers to support the medical necessity of the service being charged — diabetes may well be an accurate diagnosis, but it wouldn’t support the need for a thyroid FNA charge.
  4. Inaccurate or Invalid ICD Codes Supplied
    Does your requisition have ICD-9 codes on it, or a blank line for the clinician’s ICD-9 code? If you have actual codes, those codes will be obsolete after September 30, 2015. It’s not too early to start updating your requisition to include ICD-10 codes, and making sure your referring physician offices understand to only use the ICD-10 codes after October 1. If your requisition has a blank line for ICD numbers, updating your forms shouldn’t be required, but ICD-9 or ICD-10 numbers can easily be transposed or digits can be missing. Create a “cheat sheet” for your most common diagnosis codes, and use it to check your requisitions against to help ensure that your referring physician offices are using valid codes.
  5. Products of Conception, Delivery and Placentas
    Even in ICD-9, these specimens’ diagnosis code options are often more specific than the information supplied. For example, were the products of conception the result of a missed abortion, legal abortion or was it a retained placenta post-delivery? For placenta specimens gestational age, whether vaginal or C-section delivery, documentation of normal vs. complications during labor/delivery is required. Visit your labor and delivery and outpatient departments to educate the nursing staff on the kind of specificity you need, or review the EMR on these cases and include the details in your clinical histories.
  6. Pap Smears and Pap-specimen Tests
    Medicare requires that we distinguish diagnostic from screening, and if screening, distinguish high-risk screening from low-risk screening for payment of Pap tests. Many state Medicaid plans require distinguishing for family planning, and many commercial payers require only diagnostic vs. screening. For any additional testing performed on the Pap specimen, we need the reason for each test, though rules vary between payers and between tests — the Pap code doesn’t necessarily explain the need for additional tests. Creating a user-friendly requisition to prompt the clinician to provide all of this information upon ordering the services is imperative.

Key Points:

  • Check all requisitions for complete diagnosis information, and contact referring MDs or hospital personnel or records if sufficient information is not provided.
  • Monitor the cases your billing vendor returns to you for incomplete diagnosis information and identify common threads, such as repeat offending referring MDs, surgical nursing staff or types of specimens.
  • Address the errors at the source, and track them to help ensure issues are being fixed. Focus on higher dollar and higher volume first.
Author - Male

About the author

Chappy Manning, RN, CPC of Compliance - Pathology and Laboratory, McKesson Business Performance Services.