"It is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement."

This statement from the American Hospital Association (AHA) Coding Clinic (fourth quarter, 2015) may come as a surprise to many physicians who order diagnostic tests, since they have always assumed that the diagnosis code is enough. The AHA's recommendation came in response to the following request:

"Since our facility has converted to an electronic health record, providers have the capability to list the ICD-10-CM diagnosis code instead of a descriptive diagnostic statement. We are seeking clarification for whether there is an official policy or guideline requiring providers to record a written diagnosis in lieu of an ICD-10-CM code number."

In addition to the above statement, AHA also explains in its answer why an ICD-10 diagnosis code is not enough on an order:

"ICD-10-CM is a statistical classification, per se, it is not a diagnosis. Some ICD-10-CM codes include multiple different clinical diagnoses and it can be of clinical importance to convey these diagnoses specifically in the record. Also some diagnoses require more than one ICD-10-CM code to fully convey the patient's condition. It is the provider's responsibility to provide clear and legible documentation of a diagnosis, which is then translated to a code for external reporting purposes."

Addressing uncertainty

Section IV - Diagnostic Coding and Reporting Guidelines for Outpatient Services of the 2016 ICD-10-CM Official Guidelines for Coding and Reporting expands upon the AHA recommendation by saying the following about "uncertain" diagnoses:

"Do not code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit."

If an ordering physician gives an uncertain diagnosis as the clinical indication, radiologists or their coding staff should ask which of the patient's symptoms point toward that possible diagnosis. In its Practice Parameter for Communication of Diagnostic Imaging Findings, the American College of Radiology (ACR) states that clinical signs and symptoms included in an imaging request should be "pertinent."

ACR's parameter suggests that ordering physicians include a specific question to be answered. "Such information helps tailor the most appropriate imaging study to the clinical scenario and enhances the clinical relevance of the report, thus promoting optimal patient care," it explains.

Using the above guidance, radiologists and their staff may want to develop a list of tips that can be provided to ordering physicians. Examples of what might be included are as follows:

• Indicate clearly why a particular study is being ordered. Be specific and complete when stating the reasons for the study.
• Provide more thorough clinical histories and specific diagnostic questions that need to be answered by the study.
• Clarify exactly what answers or results you are looking for in a given study.
• Choose the most appropriate study. Discuss this with the radiologists if needed.

Changing the order

It's also important to consider the following, which applies to an interpreting physician of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient.

What if the radiologist or another interpreting physician determines that a different diagnostic radiology test than the one ordered would be more appropriate? The answer depends on whether the radiologist can reach the ordering physician or practitioner, according to chapter 15, section 80.6.2, of the Medicare Benefit Policy Manual.

The interpreting physician may not perform the unordered test until a new order from the treating physician has been received. Similarly, if the result of an ordered diagnostic test is normal and the interpreting physician believes that another diagnostic test should be performed (e.g., a renal sonogram was normal, and based on the clinical indication, the interpreting physician believes an MRI will reveal the diagnosis), an order from the treating physician must be received prior to performing the unordered diagnostic test.

However, section 80.6.3 states that if the testing facility cannot reach the treating physician or practitioner to change the order or obtain a new order and documents this fact in the medical record, the additional diagnostic test may be performed if all of the following criteria apply:

• The testing center performs the diagnostic test ordered by the treating physician/practitioner.
• The interpreting physician at the testing facility determines and documents that because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary.
• Delaying the performance of the additional diagnostic test would adversely affect the care of the beneficiary.
• The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary.
• The interpreting physician at the testing facility documents in his/her report why additional testing was done.

The U.S. Centers for Medicare and Medicaid Services (CMS) gives the following as examples:

• The last cut of an abdominal CT scan with contrast shows a mass, requiring a pelvic CT scan to further delineate the mass.
• A bone scan reveals a lesion on the femur, requiring plain films to make a diagnosis.

From order to payment

Most imaging tests (except for self-referred screening mammograms) start with an order from a referring physician, but they don't, of course, stop there. Even though the reason for the exam related to the diagnosis is an important piece of documentation, the patient's medical record also must include dictated reports and must meet medical necessity guidelines from payors.

Adhering to the guidelines above and working with referring physicians so that they understand the information that the radiology department or imaging center needs to submit a claim takes teamwork. Consideration should be given to developing policies and procedures that will lead to proper payments.

Catherine Huyghe, a senior healthcare consultant with Panacea Healthcare Solutions, has more than 30 years of experience in the interventional radiology and cardiology auditing, revenue cycle, and management industry. She performs cardiology, interventional radiology, image-guided invasive procedure, electrophysiology, and radiology procedure-based CPT and ICD-10 diagnosis coding audits; charge master assessments; reviews for regulatory agency compliance; and evaluations of administrative policies and procedures. She also assists in the development of compliance programs and conducts radiology, electrophysiology, interventional radiology, and cardiology educational training seminars.