Pediatric Coding Alert

Question: When a patient returns to the office for review of her lab results, what procedure codes and diagnosis codes should I use?

For instance, the patient had blood drawn in the office. We obtained the results from the outside laboratory.What procedure code and what diagnosis code should apply for the return visit to obtain the test results?

Florida Subscriber

Answer: The diagnosis you use depends on the individual encounter. There is no one specific ICD-9 code for reviewed results. Youll instead code what you know at the end of the encounter:

" If the results discussed with the patient are positive for a definitive diagnosis, use that ICD-9 code.

" If the results are negative, you can use the signs and symptoms that you used on the original encounter, in which the tests were ordered.

For the CPT code, report the appropriate level office visit (99212-99215). You can consider reviewing test results as part of Reviewed Data under medical decision making. The Marshfield Audit tool and CMS standard Documentation Worksheet assign 1 point for reviewing clinical lab tests.

Remember: If counseling comprises more than 50 percent of the face-to-face time that the physician spends with the patient, you can use time as the controlling factor when selecting the level of EM service. This time should be carefully documented!

Suppose the patients blood work indicates a diagnosis that requires the pediatrician spend the majority of the encounters time counseling the patient on possible treatment and management options. The physician documents the encounters total face-to-face time,indicates that counseling dominates, and briefly summarizes the counseling. He could assign 99212-99215 based on the encounters total face-to-face time.