Primary Care Coding Alert

Question: We performed a strep test on a patient who presented with vomiting, rash, and headache. She didn't have pharyngitis, scarlet fever, or tonsillitis. The strep test was negative, and the payer denied the claim. Any suggestions on how to handle the situation?

Georgia Subscriber

Answer: First, clarify why the payer denied the claim. If the reason for denial is that the payer did not consider the strep test medically necessary, given the absence of pharyngitis, scarlet fever, or tonsillitis, then the physician should write a letter appealing the claim and noting that, based on his clinical diagnosis, the patient exhibited other symptoms of strep. For example, the combination of headache (784.0), abdominal pain (789.00), and vomiting (787.03) led the physician to believe that the patient may have been experiencing strep throat. If the patient mentioned exposure to strep at work or at home, the physician should mention that in his letter, and you should report the appropriate V code for it (for instance, V01.89, Contact with or exposure to other communicable diseases).