Ob-Gyn Coding Alert

Question: It looks like my providers recently started selecting their own ICD-10-CM codes. They are choosing screening codes, such as Z12.31 and Z12.11 as diagnosis codes with their evaluation and management (E/M) visits when they order the tests. These are tests that will be done at external facilities at a later date. We do not perform these in the office. Should we be reporting these codes?

AAPC Forum Subscriber

Answer: No. Report screening codes such as Z12.31 (Encounter for screening mammogram for malignant neoplasm of breast) and Z12.11 (Encounter for screening for malignant neoplasm of colon) when the screenings themselves are the reason for the encounter e.g., the decision to order the screenings did not occur during the E/M encounter. These are the codes that support the order for the lab work, not the reason for the visit.

EHR alert: Many electronic health record (EHR) systems will automatically pull any diagnoses that were used during the encounter and place them into the assessment and plan (A/P) sections of the medical record. This includes screening codes or other diagnoses that will be used for future labs. Systems might also suggest codes when a provider is filling out the record. This can lead to providers selecting inappropriate codes if they aren’t educated on guidelines or proper usage. Be sure to keep a line of communication open and query your provider if ever you have questions.