Hint: Select the diagnosis code based on the physician's documentation, even if you end up reporting V65.2. 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:
It is probably best, however, to discuss the diagnosis coding with the practitioner that 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.