Primary Care Coding Alert

Question: A patient came in complaining of back pain and said he was leaving the country and would need immunizations. Instead of having the patient make a new appointment, the doctor performed a hepatitis screening, an HIV test, a lithium level test, a TB test and gave him a tetanus shot. The physician documented back pain for the diagnosis, but I dont think this will help the tests get reimbursed. Which codes should we use?

Nevada Subscriber

 
Answer: You are correct in assuming that a diagnosis of back pain will probably not support reimbursement for those tests. If any service was provided for the patients back, link 724.5 (Backache, unspecified) to the CPT codes representing the services performed for that problem, (i.e., any x-rays ordered/performed). Use the appropriate V code for the screening tests (e.g., V74.1, Special screening examination for bacterial and spirochetal diseases, pulmonary tuberculosis) and injections (e.g., V03.7, Need for prophylactic vaccination and inoculation against bacterial diseases, tetanus toxoid alone).