Wiki Help needed, when can screening codes be used

[pamelat]

Could really use some help in understanding when screening codes can be used. I was under the impression that they can only be used during a preventive care visit. Please help me understand. How should this visit be coded?

In HPI, Physician documented patient came in to establish care. Patient complains of back pain.

Full exam is taken.

In Assessment/Plans the physician documents the following diagnosis:
back pain 724.5
polydipsia 783.5 (lab - 83037, w/36416)
polyuria 788.42
peri-menopause 627.2
screening for colon cancer V76.51
screening for mammogram V76.12
screening for thyroid disorder V77.0 (labs 80061, 86141)
screening for lipoid disorders V77.91
screen, endocrine/nutrition/mtb disord V77.99 (lab 80053 w/36415)
encounter to establish care V65.8

Mentions patient is not yet diabetic but has symptoms, will discuss diet/exercise changes at next visit and will also go over labs and do her well woman exam.

 

[rryder1963]

Are you billing for the preventive services code only and no OV?
I mean, is that all the documentation the doc did?

 

[mitchellde]

screening is coded when the patient is documented as asymptomatic and wanting a screening as a preventive measure. It appears that this patient is symptomatic and these tests are being order as a diagnostic tool to assist the provider in determining a definitive diagnosis. therefore you bill with the symptoms and not a screening V code. If the patient has a condition that they take medication for then it is not a screening even though the patient is currently asymptomatic, so in that instance you use a V58.83 with a V 58.6- code for drug monitoring.
Also the V65.8 is first listed only allowed.

 

[pamelat]

This was a regular e/m office visit. My question is can I submit screening diagnosis during a problem oriented visit or just at a preventive visit?