There are many reasons that a patient might report to a physician and leave the office without a diagnosis – maybe the symptoms are nonspecific, or maybe the patient requires a referral to a specialist better suited to make the correct diagnosis. No matter what the reason, coding and billing these cases can be pretty tricky. Medical claims processing is often a complicated and difficult task, and when no diagnosis is reached, properly coding these cases presents a unique challenge.
Coding a claim incorrectly can be costly for both your practice and for the patient. Few things lead to irate patients faster than an error in billing. And if you have the claim coded wrong in your medical billing software in such a way that it undercharges an insurance company, you are sure to encounter a great deal of difficulty in correcting the error after it has cleared the medical billing clearinghouse.
Accuracy in these challenging cases then becomes a high priority for you, your patients, and the insurance company. However, with care you can avoid incorrect codes and ensure your treatment and billing are seamlessly integrated. Putting in the extra time to research individual cases can often result in better care for patients and more accurate payments. Here are some tips for ensuring that your billing is accurate for these cases.
Common Circumstances Where No Diagnosis May Be Reached
There are several circumstances that may arise for a doctor/patient visit that does not result in a diagnosis being reached. For many of these circumstances, there are clear guidelines for medical claims processing on how to code and bill for these services.
Preventive care services are often covered by a patient’s insurance and can be billed under the appropriate code for the visit. These can include instances where the patient is being evaluated due to a personal history that makes a disease more likely in their case. In other cases, you may have a patient with a family history of a disease, for example, a female patient with a history of breast cancer in her family. These claims should be verified with the insurance company to ensure they are covered, but are routine in nature and should be covered by your medical billing software.
Other patients may come in for certain screenings or for prophylactic services. Typically, these screenings may not involve ultimately coming to a diagnosis of a problem, but are useful in ruling out current or future health issues. These are covered under many patients’ medical insurance plans. Check with the insurance provider to verify the benefits and process these claims under preventive health codes.
In many cases, a patient may return for a follow-up exam after a previous injury or illness has been treated. For these claims, there is no current diagnosis, nor should the claim be filed under the previous diagnosis, as that no longer applies.
However, there are codes relating to follow-up visits. Coding follow-up visits improperly is a common source of errors and should be very handled carefully. Many times, the follow-up is incorrectly billed as part of the original diagnosis rather than billed as a follow-up visit. This often results in overcharging the patient and insurance company for the visit, and may even have the claim denied under inappropriate billing codes. Be sure to use the proper follow-up visit codes to avoid this error.
Cases Where an Ill Patient Does Not Receive a Diagnosis
In many cases, patients come in with symptoms that prompt them to seek medical treatment, yet the physician can make no diagnosis. These cases often result in errors in medical billing coding due to confusion about how to handle the situation. However, in every case, a method exists for proper coding and billing for treatment.
In many cases, where a diagnosis is not immediately able to be made, the physician may observe and wait as a strategy. The patient is directed to follow a course of treatment, e.g., rest, intake of liquids, etc., and return after a specified period. In many cases, the symptoms were transient and disappear before any diagnosis can be made. In this case, the symptoms themselves are listed in the coding for the billing.
In other cases, the symptoms may not immediately lend themselves to a diagnosis; however, rather than returning for a follow-up visit, the patient may elect to find a different physician or may never return for whatever reason. In this case, no diagnosis can be made and so once again the symptoms presented are instead listed as the codes used in medical billing software.
Finally, there are some cases where, even after repeated exams and treatment, defy diagnosis, and a physician may be forced to simply attempt to treat the symptoms or provide palliative care. Here, the patient may return for treatment multiple times, and yet no diagnosis is ever reached. In these cases, once again, the symptoms presented are listed for the coding and billing.
It should be noted that in most cases, listing symptoms in the medical coding where there is a diagnosis is not appropriate. If the symptoms are integral to the diagnosis, the symptom should not be separately listed. If the symptom is not part of the diagnosis, it may be listed as part of the history of diagnosis to better explain how the diagnosis was reached, or what obstacles led to difficulties in achieving a diagnosis. In all other cases, unless a symptom is required to be listed by the classification, the symptom should not be listed.
Avoiding Overbilling for Nonspecific Conditions
ICD-10 guidelines offer clear specifications on billing codes even when a nonspecific condition presents itself and no diagnosis is forthcoming. While the process of arriving at the correct code may be confusing, getting the coding correct will lead to accurate billing, which translates into timelier payments, happier patients, and avoidance of underpayments. As such, every effort should be made to research and apply the appropriate codes, even in cases where the physician cannot make a diagnosis.
- www.aapc.com/blog/29696-icd- 10-cm- coding-tips- signs-and- symptoms/
- www.cms.gov/Medicare-Medicaid- Coordination/Fraud-Prevention/Medicaid- Integrity-Education/Downloads/docmatters-presentation- handout.pdf