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Encounter for Protime level

  1. Default Encounter for Protime level
    Medical Coding Books
    Patient was in ER day before for a contusion of the head. She is on Coumadin and her PT & INR were elevated so she returns for a recheck of the PT & INR. What would be the code for this?


  2. Default
    Consider Z51.81, encounter for therapeutic drug level monitoring, as the primary diagnosis plus additional code Z79.01, long-term (current) use of anticoagulants. If the reason for anticoagulation is given/known, you may use that as the primary diagnosis instead of Z51.81 but still use additional code Z79.01. If the contusion is addressed/treated, you may also code that, but your post indicates the reason for the visit is to check the PT/INR.

    The above is the information I have gotten from searching this topic on this forum, so you might also try a search for further information or to see how others handle it. I found slightly different ways, but the above is how I will code encounters for PT/INR monitoring.

  3. Default
    Thank you!

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