Pathology/Lab Coding Alert

Question: If a referring physician tests a patient for chlamydia and receives a claim rejection for the screening, what can be done if the results come back positive? Can the physician refile to the insurance company with the new diagnosis for the patient who was originally rejected for routine screening?

New Mexico Subscriber

Answer: It is not a good medical coding practice to perform screening tests and then rebill the tests with positive results by changing the diagnosis code. It is certainly correct to place the diagnosis of chlamydia infection in the medical record based on the lab results and the physicians clinical examination. But to change a diagnosis to receive reimbursement on a previously billed claim is not correct.

You should code the diagnosis based on the reason the culture was taken. Does the patient have a vaginal discharge? Is there a personal history, such as an infected sexual partner, that indicates exposure to the organism? If these symptoms or conditions exist, they should be reported as the reason for the test. Even if the patient has no symptoms, but has exposure or history indicating a possible infection that warrants the test, then the appropriate V code should be used.

Your question suggests that better medical documentation and a better understanding of the concept of screening tests could possibly avert the reimbursement problem. If the patient presents with signs and symptoms of disease that prompt the physician to order a test (e.g., 87110, culture, chlamydia, any source), it is not a screening test. A screening test is ordered in the absence of signs and symptoms of disease. Even before the lab results are in and a definitive diagnosis made, coding the symptoms that were the reason for the test should be sufficient to avoid a claims denial.

The concept of a screening test can be confusing because the physician, and even the code itself, may use the word screening in a different sense. For example, if a physician orders a test or multiple tests seeking classification of an unidentified organism, the process may be referred to as screening for the causative agent of disease. Even so, this would not be considered a screening test if ordered based on symptoms and the physicians suspicion of disease.

This situation requires good medical documentation. If the physician records the presenting signs and symptoms rather than simply stating screen for chlamydia the coder can assign the proper ICD-9 code for signs and symptoms and perhaps gain reimbursement that would otherwise have been denied.

Answered by William Dettwyler, MT-AMT, an independent pathology coding consultant based in Salem, Ore.