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Radiology reports may support medical necessity

APCs Weekly Monitor, February 6, 2004

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Can radiology report findings support medical necessity?

QUESTION: When you have an observation/ambulatory surgery account, can the findings from a radiology report be used to support medical necessity even though the attending physician doesn't have documentation to support medical necessity?

For example, a patient comes in with shortness of breath (SOB) as an observation and the attending physician orders a computed tomography (CT) scan of the head. There is no documentation as to why this was ordered--no mention of confusion or dementia. The CT scan shows cerebral cortical and cerebellar atrophy. In the summary, the attending physician states that the CT scan of the head was unremarkable or the physician doesn't mention the CT results in his summary. Can cerebral cortical and cerebellar atrophy be coded since it meets medical necessity?

ANSWER:Yes. For outpatient claims, providers report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in Form Locator (FL) 67. For instance, if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported (786.2). If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported (466.0). If the patient arrives at the hospital for examination or testing without a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital reports an ICD-9-CM code for "Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations" (V70-V82).

Examples include

• routine general medical examination (V70.0)
• general medical examination without any working diagnosis or complaint, patient not sure whether the examination is a routine checkup (V70.9)
• examination of ears and hearing (V72.1)

For outpatient claims, providers report the full ICD-9-CM codes for up to eight other diagnoses that existed in addition to the diagnosis reported as the principal diagnosis. For instance, if the patient is referred to a hospital for evaluation of hypertension and the medical record also documents diabetes, diabetes is reported as another diagnosis. FL 76 on the Form CMS-1450 is defined as Admitting Diagnosis/Patient's Reason for Visit is required for inpatient hospital claims subject to peer review. The admitting diagnosis is the condition identified by the physician at the time of the patient's admission requiring hospitalization. For outpatient bills, the field is defined as Patient's Reason for Visit and is not required by Medicare but may be used by providers for nonscheduled visits for outpatient bills.

Note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results. In this instance the SOB (or reason for the SOB) is the first listed diagnosis and the diagnosis from the CT scan can be assigned as a secondary diagnosis.

For more information, see Medicare Claims Processing Manual, Chapter 23, Fee Schedule Administration and Coding Requirements.

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