Pediatric Coding Alert

Question: If we have a patient that comes to our practice for a lab draw, and the patient does not have a definitive diagnosis, is it possible to use Z01.89?

Georgia Subscriber

Answer: At the beginning of the Z01.- (Encounter for other special examination without complaint, suspected or reported diagnosis) code block, there is an Excludes1 note, which tells you that if encounter is “for laboratory, radiologic and imaging examinations for sign(s) and symptom(s)” then you should “code to the sign(s) or symptom(s).”

That means you can use Z01.89 (Encounter for other specified special examinations) in this case providing you include a sign or symptom code in your documentation that demonstrates the need for the lab.

The code’s descriptor also notes that the documentation needs to specify the procedure your provider performs. That, along with another note accompanying the code block that tells you “a separate procedure code is required to identify any examinations or procedures performed,” reinforces the notion that you can use the code if you have documented the appropriate exam or testing service related to the patient’s sign or symptom.