Coding labs diagnosis with an office visit
I was taught that you always code to the fullest every time.
If patient is in for DM and GERD but has other labs done - you would want to code the works if it is part of the office visit.
I'll throw an example -
Patient is in for CKD 3 and has hypertension and Vit D deficiency.
You would want to use 585.3, 430.90, and 268.9
It's the same scenario for pathology.
Patient has a mastectomy for invasive breast CA, ductal CA in situ, & Estrogen receptor negative.
I would code 174.9, 233.0, V86.1 with V45.71
Which is CA of Breast, ductal CA in Situ, Estrogen Receptor negative, and absence of breast.
Thanks,
Dana Chock, CPC, CCA, CANPC, CHONC
Anesthesia, Pathology, and Laboratory Coder