Question Diagnosis code

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26
Location
Portland , OR
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0
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
 

fwnewbie

Expert
Messages
284
Location
New Haven, IN
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0
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

New
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2
Location
Penacook, NH
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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.
 
Messages
408
Location
Clovis, CA
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1
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.
 
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