Wiki Can you code E/M for STD testing ?

[f12mfc3]

Coding OB/GYN and we have patient's come in just for STD testing; stating boyfriend cheated or they were exposed to an STD
My question is can you code an E/M visit for just STD testing with no signs or symptoms ? example -99212 with Z11.3 ? Or do they have to have signs or symptoms to code the E/M ?

Thanks

 

[CodingKing]

There is a minor E&M component to every procedure so the quick answer would be no if they are solely getting tested you wont have all the components of a separate E&M. Chief complaint would be the "my boyfriend cheated and I'm worried I may have an STD". Are the 3 key components on an E&M documented and are they medically necessary based off the chief complaint?

 

[thomas7331]

I tend to agree, though it would really depend on what exactly is documented. A true screening (Z11.3) is by definition for an asymptomatic patient, which is a preventive service and not a 'sick' visit, so an E/M would not be appropriate - it sounds like this is the case here. But if the patient has symptoms or has other reason to believe there has been an exposure to disease, and requires an evaluation to make a plan of care, Z20.2 would be more accurate and an E/M code may be supported.

 

[f12mfc3]

Thanks

I tend to agree, though it would really depend on what exactly is documented. A true screening (Z11.3) is by definition for an asymptomatic patient, which is a preventive service and not a 'sick' visit, so an E/M would not be appropriate - it sounds like this is the case here. But if the patient has symptoms or has other reason to believe there has been an exposure to disease, and requires an evaluation to make a plan of care, Z20.2 would be more accurate and an E/M code may be supported.

Thanks, that is the situation -it is not an annual/preventive service and not a sick visit because they only came in with possible exposure to STD, no signs or symptoms and we have not been coding an E/M level with this, but if we can use Z20.2 with E/M that would work

 

[Orthocoderpgu]

I think that Z20.2 is the correct diagnosis for this situation. Insurance may or may not pay, but this would be the diagnosis to choose. If signs or symptoms appear at a later date, then those can be coded at that time. Until then "exposure to" would be correct to use.