Wiki Diagnosis code

[lataashwini23@gmail.com]

we billed the claim to Medicare with DX code Z11.59 with office visit and U0002 Code. Medicare paid for U0002 but denied office visit for routine /preventive exam or a diagnostic/screening procedure done. Im not sure what other diagnosis code to use because patient was only here for testing . i have attach the chart note, can any one help me what other diagnosis code i can use to get the office visit paid. i was looking around saw DX Z20.828 but not sure if that is correct.

Chief Complaint: Covid 19 AB testing History of Present Illness: Pt is here for covid 19 AB testing, no current symptoms, no confirmed exposures, mild/mod resp illness over the past 3 months, but no hospitalizations or ED visits. Pt lives in senior care facility, but is unsure if there have been any cases of Covid 19 Review of Systems Cardiovascular: Denies Chest Pain , Cyanosis and Dyspnea on Exertion Gastrointestinal: Denies Abdominal Pain General: Denies Able to Conduct Usual Activities , Apparent Distress , Change in Strength , Comfortable , Exercise Intolerance and Fatigue HEENT: Denies Earache , Eye Pain , Eye Redness and Headaches Lymphatic: Denies Tender Lymph Node Musculoskeletal: Denies Myalgia Respiratory: Denies Dyspnea , Fever and Cough Skin: Denies Rash Vital Signs Weight 220 lbs Temp 98.30 F, Pulse 72 b/m , BP 140/60 mm/Hg SAO2 98% Taken on May 01, 2020 at 3:20 PM by MA Saechao, Farm Allergies Codeine (Drug) Current Medications Gabapentin 100 MG Oral Capsule: 1 Capsule(s) daily Aspirin 81 MG Oral Tablet Chewable: 1 Tablet(s) daily Past Medications Pyridium 200 MG Oral Tablet: 1 Tablet(s) every 8 hours PC for urinary pain, Start 10/04/2018, Qty 12 Tablet(s) For 4 Day(s), - Auto Completed on 05/01/2020 Cipro 500 MG Oral Tablet: 1 Tablet(s) every 12 hours , Start 10/04/2018, Qty 14 Tablet(s) For 7 Day(s), - Auto Completed on 05/01/2020 Physical Exam Constitutional Appearance: No distress, Alert and oriented x 3 Neck Inspection/Palpation: No sig adenopathy; Range of Motion: Supple Respiratory Respiratory Effort: No acessory muscle use no distress; Auscultation of Lungs: Normal breath sounds Cardiovascular Findings: Regular rate and rhythm, S1/S2 present Musculoskeletal Findings: Full ROM in neck Neurologic Gait and Station: Ambulatory Psychiatric Judgment and Insight: Appears appropriate Assessment And Plan: 1)Covid 19 screening – Normal Vitals, normal PE, No current symptoms. Rapid testing shows borderline + IgG and cleary + IgM in clinic today. Results reviewed with pt extensively. Diagnoses Encounter for screening for other viral diseases - Z11.59

 

[SharonCollachi]

Why would you perform an office visit if they were only there for the virus screen? There is no chief complaint.

 

[fwnewbie]

Patient reports having respiratory symptoms, lives in a senior care facility (high risk) and is not noted to be an established patient so would have New Patient status. Any conscientious provider is going to do a complete exam.
I my mind, this visit should be paid as an office visit with screening. Just because the Diagnosis is listed as "Encounter for screening" doesn't exclude the fact that a complete physical exam was warranted and kudos to the provider for doing such a thorough job!

 

[jduclos]

In my mind, the provider needs to document specifically the mild respiratory symptoms. The office visit would then have those codes for the respiratory symptoms which should then be paid.

 

[SharonCollachi]

Patient reports having respiratory symptoms, lives in a senior care facility (high risk) and is not noted to be an established patient so would have New Patient status. Any conscientious provider is going to do a complete exam.
I my mind, this visit should be paid as an office visit with screening. Just because the Diagnosis is listed as "Encounter for screening" doesn't exclude the fact that a complete physical exam was warranted and kudos to the provider for doing such a thorough job!

A lot of places are doing "drive-up" virus screening, where you're not even seeing a doctor. That's why I asked why they did an exam - was it supposed to be a "drive by" screening? And FWIW, it looks like those symptoms were discovered after the patient was roomed, because they weren't there for respiratory problems.

And lastly, I put about zero stock into EMR notes. I got one last week from a psychiatrist that, according to the EMR, did a thorough exam of ALL of the systems, including a gynecological exam. Now I don't know about anybody else, but I certainly don't see a psychiatrist and expect a gyno exam, nor do I expect to see a description of one in my medical records.