Program_Memos / 2001 / AB-01-144

Why This Topic Matters

Accurate diagnosis reporting affects claim submission, documentation alignment, and coding consistency for diagnostic services. This memorandum helps readers understand the scope of Medicare expectations for diagnostic test-related diagnosis coding and documentation.

Article Sections

1. Diagnostic test ordering and source of diagnostic information

   Explains Medicare expectations for diagnostic test orders and the types of communication that may constitute an order. It also addresses how diagnostic information may be obtained when the referring physician is unavailable.

2. C. Incidental Findings

   Discusses how incidental findings are treated in diagnostic test reporting. Several examples show the general handling of additional findings discovered during interpretation.

3. D. Unrelated/Co-Existing Conditions/Diagnoses

   Addresses reporting of unrelated or co-existing conditions identified during diagnostic testing. The section provides a broad example of additional diagnosis reporting.

4. E. Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms (e.g. screening tests)

   Covers diagnostic tests ordered without signs, symptoms, or other evidence of illness or injury. It explains the general reporting approach for the reason the test was ordered and the test results.

5. F. Use of ICD-9-CM To The Greatest Degree of Accuracy and Completeness

   Summarizes ICD-9-CM specificity principles and the importance of complete diagnosis code assignment. It also references general digit-level coding guidance and supporting official sources.

6. Attachment: Coding Clinic for ICD-9-CM Questions and Answers

   Provides a set of Q&A examples applying the memorandum’s principles across pathology, radiology, laboratory, and outpatient scenarios. The attachment illustrates how diagnosis reporting issues are handled in different test-related situations.