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Wiki Pre-employment with abnormalities

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Coder85

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Patient comes in for pre-employment physical, however, both EKG and PFT came back with abnormalities. Provider will not clear patient for work until patient has been evaluated by cardiology.

Would I code this as a pre-employment physical still even if patient was not cleared for work at this visit?
Or would I just code the abnormalities?
Or both? (physical and problem visit)

Any help is appreciated TIA.
 
Hello,

We need to code Pre-employment examination (Z02.1) as principle diagnosis along with abnormalities as secondary diagnosis.


Regards
Dr.Ramnath Bandaru, CCS, CPC
American Medical Services LLC
http://amshealth.com/
Twitter: @HospitalCoders
 
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