Primary Care Coding Alert

Question: If one of our providers saw a patient for problems related to asthma, but went ahead to write a future lab order related to the patient’s diabetes/ hypertension even though this condition was not addressed during the encounter, would you add the diabetes diagnosis to the evaluation and management (E/M) claim as well as the asthma diagnosis?

Codify Subscriber

Answer: In order for your provider to order a lab, he or she must designate whether the test is for screening purposes (for a condition that the patient has no known history of) or monitoring purposes (for a condition that the patient has either had or continues to have).

For screening tests, you would use an encounter code from Z13 (Encounter for screening for other diseases and disorders) based on the condition for which the patient is being screened. When the patient’s condition is known, as in this case, then the appropriate diagnosis code for the condition being monitored must be given. So, you would give the specific code from E08-E13 (Diabetes mellitus) in order to justify the provider ordering the test. It may also be appropriate to add the diabetes diagnosis secondary to the asthma to the extent that, as a comorbid condition, it may impact the physician’s medical decision making related to the asthma.