Anesthesia Coding Alert

Question: Our practice recently had a patient presenting with a complaint of severe low back pain. When our pain management specialist completed the history and physical exam, she suspected the patient of malingering and potentially misrepresenting his complaints to obtain a narcotic prescription. The staff informed the patient of the practice's required policy of reviewing the prior provider's notes, a signed narcotic agreement, and random urine drug screen (UDS) testing. The patient declined the UDS and chose to leave. I still need to code for the encounter, so what should I report for the diagnosis?

California Subscriber

Answer: Like any scenario, you should select the diagnosis code supported by your physician's documentation. If she states in the notes that she believes the patient isn't suffering from the condition presented, you should report V65.2 (Person feigning illness).

However, it is probably best to discuss the diagnosis coding with your pain management specialist to determine whether a more "typical" code would be more appropriate. If your specialist included low back pain in her documentation, you could report an ICD-9 code such as 724.2 (Lumbago).

Take note: If your physician believes that the patient is looking for an illegal prescription, you may want to recommend flagging the patient's chart for future reference.