Question: Screening Labs

TThivierge

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Atlanta, GA
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Hi Rhonda😊
This screening depends on what lab test is being done and reason from provider. . DX Z00 is more of physical. I'd be detailed if I were you 2. Let me give you some examples but it depends on why doc is wanting the lab.

Occult Fecal Test 82270 87177 87045 Possible Dx R15, K92, K59.89 K29.60 dx Z12.11

PAP 88035 88141 88143 Possible Dx R87.62 D28.9 dx Z01.411, Z01.419

Pregnancy Test urine/blood 81025 Possible DX 026.9, Z34.90 Z32.01 Z36.9

PSA Prostate 84153 N52, N40 N42.9 E29.1 Possible Dx Z31.41 or Z20

Testosterone 84402 N46, N51 N52.9 Possible Dx Z31 or Z20

Covid 19 /SARS 87811 86769 86318 Possible Dx J39.8 J98.8 Z11.52 UO7.0+

Colon bx polyps 88305 Possible DX D12, K63.5, Z12.11

Vitamin D 82607 Possible Dx E55.9 Z13. 21

I hope this data helps you understand lab coding. I d put the Z code last
Have a good day!
Lady T:)
 
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Manhattan, MT
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Thank you for your response. I agree with your response. Trouble is getting doc's to be more specific in their diagnosis on these labs and not just indicate screening and to give a reason for the test. Working on some education with the doc's on this. I was putting my Z code last when I had other possible dx as to the reason the test was ordered and had feedback from another coder to list it first which also had me a bit concerned. If doc's have no other reason for the lab test and it is just general screening then do you ever use the Z139 or do you recommend a more specific code?
 

OpenClaims

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Miami, FL
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What dx code are others using for a diagnosis of "Screening" on a lab order? I have used Z13.9 and my manager is wondering if we can use Z00.00?
Hi! If you're main concern/issue is needing the provider to document with more detail in regards to this, I'd highly recommend reaching out to your manager to see if something can be initiated through your facility's Provider Education team. If you don't have a Provider Education team, the next would be Compliance.
 

TThivierge

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Open Claims is correct. Most times doctors put in his daily documentation lab he or she is ordering & reason. CMS request this as part of regulations . At time we match the dx code he used for the day or the ongoing chronic list if is not more than 2 year old. However the provider maybe testing for something else which may or not be inferred as exact dx code given for that day of treatment. Sometimes from reading type of lab code it is give you a clue but really should not have to guess. . You can always query them but part of CMS policy the provider needs to list why the lab test is being done...part of medical necessary & enter in chart of treating notes or add addendum for the patient in the EHR system. Lab orders can be a separate section in your EHR systems. Plus our providers do a email to patient listing lab or xray tests if it is normal or notice abnormalities. This helps the coder to when billing and assigning the dx codes linked with lab codes
CMS states the physician order must either be in the documentation or the lab orders accompany documentation for the treatment day. However at times pt. show up cause nurse has called pt. come in per provider 's order to get lab or xray done. Following the CMS regs does causes less confusion.
:) Oh yes there are screening codes section in the ICD10 manual usually dx Z11-Z13 pertaining for what ds. searching for. Most Z dx code have star or mark in ICD10 manual telling you if first listed Z dx codes. if it is not first listed Z x code I d put last on claim unless that is all you have . Sometimes we use dx Z01.89 for lab order.
Well hope this data helps you
Lady T
 
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