Wiki Encounter for entry into a Methadone Clinic

[cris722]

A patient came into the office today for a entry examine into a Methadone clinic only issue he had was Hypertension.

Diagnosis Codes that were billed I10 and Z00.8.

The claim came back denied due to Missing/incomplete/invalid diagnosis code or condition.

Having trouble on a diagnosis code/s any advice would be wonderful.

Thanks in advance.

 

[thomas7331]

If the exam was for admission to a Methadone clinic, then I would think the primary diagnosis should match the reason for the admission, which is likely for a substance abuse or dependence problem of some sort, since this visit is part of that course of treatment for that problem. I would query the provider for additional information if this wasn't documented in the record. I would also remove diagnosis Z00.8 - the Z00 category is for an exam that is "without complaint, suspected or reported diagnosis", since the patient clearly isn't without a diagnosis, and so this code isn't appropriate.

 

[cris722]

If the exam was for admission to a Methadone clinic, then I would think the primary diagnosis should match the reason for the admission, which is likely for a substance abuse or dependence problem of some sort, since this visit is part of that course of treatment for that problem. I would query the provider for additional information if this wasn't documented in the record. I would also remove diagnosis Z00.8 - the Z00 category is for an exam that is "without complaint, suspected or reported diagnosis", since the patient clearly isn't without a diagnosis, and so this code isn't appropriate.

Thank you...I took your advice and queried the physician due to very little documentation in the patients chart.
He did not treat the hypertension only stated in the patients chart, "has history of hypertension", but put hypertension as the only diagnosis.
He did tell me the patient was being admitted due to opioid dependence. So I am thinking the hypertension is incorrect as well?

 

[thomas7331]

Thank you...I took your advice and queried the physician due to very little documentation in the patients chart.
He did not treat the hypertension only stated in the patients chart, "has history of hypertension", but put hypertension as the only diagnosis.
He did tell me the patient was being admitted due to opioid dependence. So I am thinking the hypertension is incorrect as well?

I would assign opioid dependence as the primary diagnosis since that is the reason for the admission, and therefore the reason for this visit. Hypertension can be assigned as an additional diagnosis if it is still a current condition. (When physician's use the phrase 'has a history of...', it can sometimes be unclear whether or not the patient still has the condition.)

 

[cris722]

Thank you so much for your help. It is greatly appreciated. And yes it seems like I see, "has a history of" in almost every single patient's chart!