Wiki Routine Labs-Please tell me

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NESmith

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Please tell me how you would handle this.
CC-Annual Review
HPI_ The patient is a 68-year-old white female that presents today for her annual physical. She was recently seen by another EP physician for eval of palpitations. Workup included a nuclear stress test, echocardiogram, and Holter. She was prescribed proapfenoneprn for symptomatic palpitations. Pt has not taken any yet as she is concerned about side effects. Some of her palpitations apparently associated with near syncope. No chest pain or other concerning neurolgical sx's. Pt's ACE inhibitor has been reduced over the past one year..She is on a alpha blocker per urology. She was also told to take doxazosin "the rest of her life". EKG with RBBB and LAFB. She continues to smoke. No headaches, paresthesias, weakness, dysarthria, or incontinence.
Pt. declines any mammograms or vaccines.

List of current Medication-I will not list because of the amount.
Past medical/Surgical Hx
Reported: Pregnancy" Gravida 3, para 3, and aborta 0.
Diagnoises:
Hypertension, GERD, IBS, Menopause approx 41 yrs of age-partial hysterectomy, hyperlipidemia, thyroid disorder s/p FNA, asthritis, anxiety disorder NOS, cancer squamous cell excised from rt thigh. Possible colovaginal fistula with chronic constipation. She was evaluated by another physician but declined repair of fistula & colostomy.
Surgical HX-once again-numerous
Social and Family Hx also listed.
Complete ROS

Exam: Vitals
General: General appearance-no acut distress
Skin: No rahsed of lesions
HEENT: Pupils round and reactive to light Extraocular muscles intact. Oropharynx is clear without erythema or exudate. Edentulous other than two bottom teeth.
Neck: Supple. No JVD or adenopathy. Thyroid not enlarged. No carotid bruits.
Heart: Regular. Normal S1, S2. No murmurs, gallops or rubs.
Liung: Clear to auscultation and percussion.
Breast: No palpable masses, skin changes, or nipple discharge. Axilla benign.
Abdomen: Soft. minimal tenderness with deep palpation. no hepatosplenomegaly. Active bowel sounds.
Pelvic/Rectal Exam: Deferred
Extremities: No peripheral edema, cyanosis or clubbing. No calf tenderness. Distal pulses grossly intact.
Neurologic: no focal motor or sensory deficits.
Test:Imaging: Bone Density Studies: Bone density studies were preformed 1/13/11 IMC
Assessment:
Well female physical
Palpitations, osteopenia, neurogenic bladder on alpha blockers, hypertension, IFG, bifascicular block, possible colovaginal fistula, deferring surgical intervention. Hx of ileostomy status post reverdal 2002
List of previos test were given. Providers List provided. Health Reminders Done.

Ok, here is my problem(after all of that) Patient was given a lab order for CMP, Lipid panel, TSH, Free T4, CPK, CBC with dx:401.9, 272.4,300.00, 503.81, 733.90.
labs were paid to the patient's deductable and now the patient is calling and complaining that these should have been billed as "Routine" so her insurance would paid at 100%.
What is your take on this. Please let me know and Thanks for your help in this matter.
 
I'm eager to see what people say about this as well. I have had this issue with a child well check-up who's "routine labs" were suppose to be paid at 100%. However, the provider billed it with a dx of "fatigue" because she wanted to run labs that she didn't interpret to be routine. I think the issue lies within defining what "routine labs" are. I called the insurance carrier and they were unable to tell me.

But in response to what you posted, if this is routine shouldn't the primary dx be a V70.X or a V72.63 followed by additional dx's? Was it communicated to the insrance that this was an annual visit or did the insurance interpret it to be that the pateint was having a problem controlling her HTN, ect?

Sorry if I didn't answer your question. :eek:
 
routine lab comment

:) I agree the diagnosis will drive whether they pay at the routine rate or if they are applying to the deductible. At least that is how it was when I worked for BCBS. The primary diag pointer drives what it processes to.

Phyllis D- CPC,CPC-P, CPC-I
 
Well, if it's not a new problem and it is not exacerbated or giving her any trouble, then it's not like she came to the Dr with a complaint. It was just time for her to have a check up. If you read the coding guidelines you will see that you are permitted to code V70.X followed by other Dxs. Like it was said previously, if you code it as routine then the insurance company will know that this is just a yearly, not a visit because of an illness that has exacerbated. If the insurance company has allowed a certain price to be paid for "routine labs" then this would be when you would use that. Anyone correct me if I'm wrong.
 
Did he bill a preventive visit code? what was the reason for the labs? was it due to the drugs she is taking? if so then it should be coded to V58.83 with the appropriate V58.6x code for each test. It says under chief complaint this is for the annual review so the V70.x is correct but it must be paired with the prevent level, the tests then are either for screening or to check the drug levels and so appropriate V codes should be applied. ICD-10 CM codes for the annual Z00.00 will not allow additional codes other that other Z codes be appended.
 
The visit was billed with V70.0. But when the patient was given the order for the labs, the provider put on the patient's diagnoses. So I can change these to V70.0 plus the additional dxs even though the lab orders did not reflect "routine" as the reason for the labs?
 
you need to know the reason for each lab, it a screening then use the appropriate screening code, is it drug monitoring, then use the drug monitoring codes.
 
So the dx codes he gave you then are conditions she does not have? I am not understanding, the labs are either to screen for a condition because a patient meets certain criteria , or they are to monitor a condition the patient is known to have for which we prescribe treatment and are checking the treatment for effectiveness. This is why insurance companies do not pay for certain tests, because you cannot attach medical necessity to them.
 
No, I am sorry. I thnk I have really confused you. First the patient was given a lab order for blood work. Doctor put the diagnoses that the patient has on the lab order. Labs were done and sent to the insurance company with patient's diagnoses attached. Patient came in for her Female Well Visit. In the mean time her insurance company has processed the labs with the diagnoses billed and now the patient and doctor want the labs reprocessed with the Routine lab dx attached instead of the patient's established diagnoses because the labs processed to her deductible and if they had been processed with the dx V70.00 the labs would have processed at a 100%. So my question is can I change the dx to V70.0 and then the other diagnoses listed next because these were done for her Female Wellness visit? I hope that has made things alittle clearer and once again sorry for the confusion.
 
I do not ever use the V70.0 for labs, I always use the V58.83 with the V58.6x for the labs for conditions the patient has, if the patient is not meds for the condition then I use the V code for Lab.
 
NESmith said:
No, I am sorry. I thnk I have really confused you. First the patient was given a lab order for blood work. Doctor put the diagnoses that the patient has on the lab order. Labs were done and sent to the insurance company with patient's diagnoses attached. Patient came in for her Female Well Visit. In the mean time her insurance company has processed the labs with the diagnoses billed and now the patient and doctor want the labs reprocessed with the Routine lab dx attached instead of the patient's established diagnoses because the labs processed to her deductible and if they had been processed with the dx V70.00 the labs would have processed at a 100%. So my question is can I change the dx to V70.0 and then the other diagnoses listed next because these were done for her Female Wellness visit? I hope that has made things alittle clearer and once again sorry for the confusion.
Click to expand...

What was the reason for the provider to order the labs in the first place.
 
The original lab order is for a CMP, Lipid Panel, TSh, Free T4, CPK and CBC with a list of diagnoses: 401.9, 272.4, 300.00, 530.81, 733.90. The patient is stating this visit was not for her problems but for her Female Well Woman. Thanks for the help everyone
 
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