Medicare Compliance & Reimbursement

Question: Our practice recently had a new patient present with a complaint of severe low back pain. When our nurse practitioner completed the history and physical exam, she suspected the patient of malingering and potentially misrepresenting his complaints to obtain a narcotic prescription. The staff informed the patient of the practice's required policy of reviewing the prior provider's notes, a signed narcotic agreement, and random urine drug screen (UDS) testing. The patient declined the UDS and chose to leave; the entire visit took about six minutes. I still need to code for the encounter. What should I report for the diagnosis?

Answer: Like any scenario, you should select the diagnosis code supported by your provider's documentation. If she states in the notes that she believes the patient is suffering from the condition presented, you may consider reporting 724.2 (Lumbago) appended to 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem-focused history; a problem focused examination; straightforward medical decision making) if your doctor or non-physician practitioner included low back pain in her documentation.

It is probably best, however, to discuss the diagnosis coding with the practitioner who examined the patient to determine whether V65.2 (Person feigning illness) might actually be more appropriate.

If you believe that the patient is looking for an illegal prescription, your office staff members might want to also consider flagging the patient's chart for future reference -- that way, you'll know whether a pattern develops.