need help w/dx code please

007CPC

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Was the patient encounter for Hep Vaccine, and then diagnosed with Hep A and B. Chapter one is not my strong point but if you describe the encounter better I will give it a shot; and so will other coders because this is an equivocal scenario.

I have noticed coders will contribute their candor and enjoy rectifying scenarios once another coder has tried and is wrong.

So I would code it as a diagnosis Hep A principal/primary and B secondary, or,
code it as a V code with hep A and hep B listed as additional. So the scenario is encrypted as patient encounter for hep vacc(V code principal), code results are positive for hep A and hep B; but then V codes are used to list encounters for all but disease and injury.

My book doesn't explain how to code hepatits vaccine or virus so it will be interesting to hear a pundit response.
 
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lphillips

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I will have more info when I get the documentation - this is what the provider wrote on the charge slip. Will get back to you when all info in available. Thanks!!
 

20Hiker16

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What does the test result mean?

If the antibody test result is positive, you have probably been infected with hepatitis C, even if it was so mild you did not realize you had it.

A positive RIBA confirms that you had been exposed to the virus, while a negative RIBA indicates that your first test was probably a false positive and you have never been infected by HCV.

A positive (or detectable) HCV RNA means that you are currently infected by HCV.


There is a web site to help explain this kind of test and its results. For more information go to:

http://labtestsonline.org/understanding/analytes/hepatitis_c/test.html

Remember: Code according to what the physician has documented as the reason for the test. If he is not clear, query him to clarify these results as we cannot code without the physician's written interpretation of diagnostic services.
 

lphillips

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have the documentation/chart note now

Ok, in the documentation the physician never brings up HCV Ab+ at all.

He wrote 304.00 and HCV Ab+ on the charge slip as the diagnoses for the visit. Only discusses opiate dependence in documentation - which he is being followed for under our suboxone program.

In the chart I found lab results from last month - pt had Hep C Ab lab done that came back "reactive" w/note from lab stating "probably indicates past or present HCV infection; supplemental serologic testing not performed. Specific testing can be requested if clinicall indicated". These types of labs are normally done for patients in this program.

Physician doesn't state if any additional testing is to be done.

Looks like I should only be coding the 304.00 on this visit.
 

007CPC

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If the patient is having any manifested conditions from Opiate dependency
you should sequence the sign/symptoms as primary and 304.00 as secondary. My familiarity isn't profound with regimen for suboxone programs; but if the patient is checked inpatient you should code propable hep infection:573.3(2008) " get clarification on the HCV infection"
 
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lphillips

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We are a family practice clinic. This is the patients weekly follow up visit for opiate dependence and medication refill - no manifested conditions. Will clarify with physician re: HCV Ab+ and request addendum be added to chart stating additional info/diagnosis.
 
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