Wiki Failed DOT exam-first time encountering

[TCOIL]

I have an encounter that turned into a failed DOT exam. I have never encountered one(am very new to medical coding) and the documentation is different compared to a passed DOT physical exam. For a passed DOT p.e. we have a charge built in and use ICD 10 code Z02.4. For a failed DOT exam, would the charge remain the DOT charge, or should it be changed to a clinic level E/M charge? Or would I leave the DOT charge(as that is why the patient showed up to the clinic), use the Z02.4 code and then add the DX codes from the provider documentation? Just curious as it's common for the employer of the patient to pay for the DOT exams.

any information would be appreciated!

Thank you

 

[Orthocoderpgu]

I have an encounter that turned into a failed DOT exam. I have never encountered one(am very new to medical coding) and the documentation is different compared to a passed DOT physical exam. For a passed DOT p.e. we have a charge built in and use ICD 10 code Z02.4. For a failed DOT exam, would the charge remain the DOT charge, or should it be changed to a clinic level E/M charge? Or would I leave the DOT charge(as that is why the patient showed up to the clinic), use the Z02.4 code and then add the DX codes from the provider documentation? Just curious as it's common for the employer of the patient to pay for the DOT exams.

any information would be appreciated!

Thank you

Your provider is being paid to perform the examination on the patient and report the findings. Not everyone is going to pass the exam so they can get the required medical card signed for work, but your doctor performed the work. No coding change is required.