The Advocacy Council regularly receives queries from members on how to correctly code. Many are common issues, including for coding unconfirmed diagnoses.
Question
My providers have been taught to only use codes that are of a confirmed diagnosis. When they order labs (especially lymphocyte subsets, where they are trying to rule out a diagnosis but do not use that diagnosis in the lab order), the insurance is not paying for the lab. Is there a correct way to code these tests so the insurance will pay, but the patient will not be labeled with a diagnosis that may not be accurate and could come back to haunt them in the future?
Answer
There are certain procedures where insurance companies will only pay for specific ICD-10 codes. If this is the case, you may have to use the code they prefer if you want to save the patient the copay, etc.
ICD-10 rules say you can get labs to screen for diseases you suspect; Z codes are used in these instances. You could try to use a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (e.g., screening mammogram).
You can also work with a sign or symptom that makes you suspect a diagnosis, using the code for that sign or symptom (i.e., wheezing for PFTs). Here again, insurance companies can decide not to pay. For example, to cover FeNO testing for wheezing, some carriers require the diagnosis of asthma.
On the other hand, a patient comes into the office with complaints of symptoms and needs a diagnostic test. The sign or symptom is coded as the reason for the test. This is not considered screening.
Insurance company policy may preclude the use of nonspecific codes for billing purposes. If so, a diagnosis may appear in the patient’s chart if the goal is for their insurance to cover the cost of the tests.
The College has coding resources! Check out our Coding Toolkit, including coding webinars and Allergy Office Modules on coding, as well as many other valuable coding resources designed with your allergy practice in mind.
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The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
