Internal Medicine Coding Alert

Question: A healthy patient came to the clinic with no complaint or symptom (absolutely in perfect health), but she was in great fear that she might have a sexually transmitted disease (STD) and wanted to be tested. The physician did the test, which was sent to the lab, and then talked to her for about 10 minutes. I have two questions. 1. Should this be billed as a consult or an office visit? 2. What diagnosis should I use to bill the insurance? I understand I have to wait for the test result to come back. If it is positive, then I will bill for that diagnosis. But if the test is negative, which diagnosis code should I use?

Michigan Subscriber

Answer: Code the patient's encounter as an office/outpatient visit, using the chart documentation to determine if the visit meets the criteria for billing a 99212 (Office or other outpatient visit ...) or higher-level code The visit does not qualify as an office/outpatient consultation (99241-99245), because a consultation must be requested by another physician or appropriate source (generally a healthcare provider). You also cannot code the visit as a confirmatory consultation (99271-99275), the only consultation that can be requested by a patient, because the confirmatory consultation is a second opinion.

Code the diagnosis with V01.6 (Contact with or exposure to venereal diseases), if the patient had an encounter with someone who had a known disease. If the patient is simply concerned that she might have an STD, use V71.89 (Observation for other specified suspected conditions).

The lab tests are coded using the special screening for disease categories (V73.0-V75.9) with actual codes used dependent on the types of diseases tested. This diagnosis will not change, even if the test returns positive. Your diagnosis for a test on an asymptomatic patient is always the screening diagnosis, because your primary diagnosis must be the reason the test was performed. You can code a more definitive diagnosis after the test has been performed only in when the patient presented with signs or symptoms.