Pathology/Lab Coding Alert

Question: Noting lethargy and paleness, a physician ordered a CBC that showed normal results except for low hemoglobin. Should we use the diagnosis code for iron-deficiency anemia to bill for the tests?


Nebraska Subscriber

Answer: For clinical laboratory tests such as those included in the complete blood count (85027, Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count]), you should use the diagnosis furnished by the ordering physician. If the physician does not submit an ICD-9 code, you should select one based on the narrative diagnosis, which may be signs or symptoms that prompted the test.

In this case, you should use 780.79 (Other malaise and fatigue, lethargy) and 782.61 (Pallor) because these are the symptoms that the physician listed as the reason for ordering the test. Even if the physician had stated that the test was to -rule out- iron deficiency anemia, you should report the signs and symptoms (pallor and lethargy). You should not report a suspected condition as though it exists.

You should list the ordering signs or symptoms as the reason for the test regardless of the test results. The physician assigns a final diagnosis based on both the lab test results and other clinical information -- the lab does not assign a diagnosis based on test results alone.

If the physician does not submit an ICD-9 code or narrative diagnosis when ordering a test, you must obtain the information from the doctor.