Wiki Code positive chlamydia until negative TOC?

[mrf4d]

Hello, a patient presented for her annual exam previously diagnosed with chlamydia from another provider a month prior. She was prescribed flagyl and has a follow up appointment scheduled with that provider for a test of cure. I've always thought that we code as an active chlamydial infection (A56.X) until a negative test of cure. Problem 1. I can't find any documentation to support my thought process on that, does anyone have any info to either support or refute how to code chlamydial infections until test of cure is performed? Problem 2. If we weren't the provider to diagnose positive chlamydia (thus don't have the lab to support) would it be appropriate for me to code this on my annual exam charge as an active infection? Thank you for your help!

 

[nielynco]

Hello, a patient presented for her annual exam previously diagnosed with chlamydia from another provider a month prior. She was prescribed flagyl and has a follow up appointment scheduled with that provider for a test of cure. I've always thought that we code as an active chlamydial infection (A56.X) until a negative test of cure. Problem 1. I can't find any documentation to support my thought process on that, does anyone have any info to either support or refute how to code chlamydial infections until test of cure is performed? Problem 2. If we weren't the provider to diagnose positive chlamydia (thus don't have the lab to support) would it be appropriate for me to code this on my annual exam charge as an active infection? Thank you for your help!

If this is an annual and will be billed as a preventive service you do not have to mention the infection at all unless this is your provider's documented finding. For instance if he notes the presence of an infection on exam. I would not list this diagnosis at all since your provider is not treating her for it. It is her history, not the reason for this visit.