Wiki Screening Code Question

[ldashvt@yahoo.com]

Per the CPT code Guidelines for Screening, if the patient is presenting to the office for vaginal discharge and odor, and an STD Screening is done, what is your understanding of the coding practice?
My understanding of the guideline is:
Code the Discharge and Odor (Symptoms)
NOT the Z11.3 Screening code (Encounter for screening for infections with a predominantly sexual mode of transmission)

Source of Information in the ICD 10 book: Figure I.C.21.c.5 (screening vs therapeutic)

Thank you for and advice and help.

 

[thomas7331]

I agree - as per the guidelines, "testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening." Screenings are preventive services done for early detection of disease in patients who are otherwise well and asymptomatic.

Healthcare providers often use the term 'screening' for other things, as in your example, and in situations such as in the emergency room where they will 'screen' every patient for potentially contagious diseases prior to admission, but that would not be considered a screening service for purposes of ICD-10 reporting because the encounter is for the diagnosis and treatment of a problem, not to offer a preventive service.

 

[csperoni]

Yes, in this case I would code the symptoms. I would use a screening code if a patient came in asymptomatic, but had exposure (partner tested positive for example).