Pathology/Lab Coding Alert

Question: A clinician orders a drug test screen for a patient presenting with constricted pupils, confusion, and shortness of breath. The patient tests positive for heroin, but the physician has not provided a diagnosis of heroin abuse or dependence. What procedure and diagnosis codes should we use?

Tennessee Subscriber

Answer: For the diagnosis, you should code the ordering symptoms, such as constricted pupils H57.03 (Miosis), confusion R41.0 (Disorientation, unspecified), and shortness of breath R06.02 (Shortness of breath). You should not turn to one of the codes for opioid addition, such as F11.1- (Opioid abuse) or F11.2- (Opioid dependence), because labs do not determine the final diagnosis; that is up to the ordering physician to assign based on lab test results and clinical presentation.

For the test itself, that partly depends on your lab procedure. Choose from the following codes:

• 80305 (Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service)
• 80306 (… read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service)
• 80307 (… by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service)