Wiki Labs

[mon.1124@hotmail.com]

When a Provider see's a patient for DM and GERD, but also orders labs for B12 deficiency and Vitamin D deficiency, do the deficiencies need to be coded as part of the visit dx?

 

[danachock]

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

 

[mon.1124@hotmail.com]

Thanks The Provider didn't put the deficiencies in their visit dx's, but did order lab for these. Do the deficiencies need to be added to the visit dx's? Or is it ok for the labs to be ordered for these, but not listed in the visit dx's?

 

[Narvaez6]

As long there is documentation for the reason for the labs, it does not matter where it's documented in the record. However, it is preferable that the physician does list these conditions on the visit diagnosis.