Don’t Get Tired of Reporting Fatigue Dx With CBC
Question: Is it true that you cannot report fatigue as a primary diagnosis on outpatient labs? AAPC Forum Participant Answer: It is not true, and you can report R53.83 (Other fatigue) as the primary diagnosis in this situation. Consider the following advice found in the American Hospital Association’s (AHA’s) AHA ICD-10 Coding Clinic (2017 Vol. 4, No. 1). A patient reports to their provider complaining of fatigue and the provider orders a complete blood count (CBC), which you report with 85025 (Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count). The lab comes back showing low hemoglobin and hematocrit. However, unless the provider interprets the results and confirms a diagnosis of, say, D64.9 (Anemia, unspecified), the lab would report symptom code R53.83. Fatigue is a perfectly good reason for a provider to order diagnostic lab work, but it’s not always a covered diagnosis for a number of lab tests. However, correct coding tells you that you should code what the provider indicates on the order. So, you should report the fatigue diagnosis, though a payer may not pay you for the test. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
