Diagnosis Coding with Diagnostic Testing

January 4th, 2018 - Marge McQuade, CMSCS, CHCI, CPOM
Categories:   Diagnosis Coding   Practice Management   Diagnostic Testing  

Adequate documentation is an essential part of selecting a correct code in any setting. When providers order a test, the information that they document regarding the test results determines the primary and secondary diagnosis codes a coder assigns.

If a physician confirms a diagnosis based on the results of a diagnostic test, code that diagnosis. You may report the signs and symptoms that he or she used to order the test as additional diagnoses, but only under one of the following two circumstances:

  • When the signs and symptoms are not fully related to the confirmed diagnosis
  • When the physician cannot fully explain the reason for the signs or symptoms

For example, a patient is referred for an abdominal CT scan with a diagnosis of abdominal pain. The CT scan reveals the presence of an abscess. For coding purposes, assign a diagnosis code for "intra-abdominal abscess."

When a patient is referred for a chest x-ray with a diagnosis of "cough," and the chest x-ray reveals a 3 cm peripheral pulmonary nodule, report a diagnosis of "pulmonary nodule" and sequence "cough" as an additional diagnosis.

If the diagnostic test did not provide a diagnosis or if the test comes back normal, code the signs and symptoms that prompted the study.

For example, a patient is referred for a spine x-ray due to complaints of "back pain." A provider performs the x-ray and the radiologist indicates the results are normal. Report a diagnosis of "back pain" because the x-ray results did not show a definite diagnosis.

If the results of the diagnostic test are normal or non-diagnostic and the physician records a diagnosis preceded by words that indicate uncertainty-such as probable, suspected, questionable, working, or rule out-then you should not code the uncertain diagnosis but instead, report the signs or symptoms. Because ICD-10-CM coding guidelines deem diagnoses labeled as uncertain to be unconfirmed, do not report them. This is consistent with the requirement to code the diagnosis to the highest degree of certainty. For example, a patient is referred for a chest x-ray with a diagnosis of "rule out pneumonia." The radiologist interprets the chest x-ray, and the results are normal. Report the sign(s) or symptom(s) that prompted the test (i.e., cough).

Screening tests are performed without the evidence of signs or symptoms of a disease. For patients with a diagnosis or symptom, assign the appropriate ICD-10- CM code (and not a screening code).

When a physician orders a diagnostic test for a patient without signs/symptoms or other evidence of illness or injury, the physician interpreting the diagnostic test should report the screening code as the primary-diagnosis code. Also report any condition discovered during the screening as a secondary-diagnosis code. For example, a patient is referred for a chest x-ray as part of a routine physical. A provider performs the chest x-ray and the results indicate a lung mass. Report the appropriate screening code (in this case, a V code) as the primary diagnosis, followed by a code for the lung mass.

Never list incidental findings as a primary diagnosis. You may, however, report incidental findings as secondary diagnoses. For example, a patient is referred for a chest x-ray because of wheezing. The x-ray is normal except for scoliosis and degenerative joint disease of the thoracic spine. Report wheezing as the primary diagnosis because wheezing was the reason for the patient's visit. You may report other findings as additional diagnoses, such as scoliosis and degenerative joint disease of the thoracic spine.

You may report unrelated and coexisting conditions/diagnoses as additional diagnoses. For example, a patient is referred for a chest x-ray because of a cough. The chest x-ray indicates that the patient has pneumonia. During additional diagnostic tests, you determine that the patient also has hypertension and diabetes mellitus. You would report pneumonia as the primary diagnosis and hypertension and diabetes mellitus as secondary diagnoses.

The key is to read the documentation in the patient’s chart and rely on a version of the standard phrase “If it isn’t documented the patient doesn’t have it”. You don’t want to give the patient a diagnosis that is not consistent with what diagnostic tests have found. Never assume a diagnosis before the results of any tests are in the chart.


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....
Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?
October 10th, 2023 - Aimee Wilcox
When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.
Accurately Reporting Signs and Symptoms with ICD-10-CM Codes
October 5th, 2023 - Aimee Wilcox
Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.
The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin Resistance
September 19th, 2023 - Aimee Wilcox
Diabetes is a chronic disease that just seems to consistently be increasing instead of improving resulting in a constant endeavor by medical researchers to identify causal effects and possible treatments. One underlying or precipitating condition that scientists have identified as a precipitating factor in the development of diabetes is insulin resistance, which is a known metabolic disorder. As data becomes available through claims reporting, additional code options become possible with ICD-10-CM.
Documenting and Reporting Postoperative Visits
September 12th, 2023 - Aimee Wilcox
Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period? 
Understanding Gastroesophageal Reflux Disease and ICD-10-CM Coding
August 22nd, 2023 - Aimee Wilcox
Gastroesophageal reflux disease or GERD for short, is a disease that impacts millions of Americans on a weekly basis. Symptoms are uncomfortable, as are some of the tests used to diagnose it, but understanding the disease, tests, and treatments helps us better understand how to code the disease using ICD-10-CM codes.

Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2023 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association