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ordering a test for a patient without symptoms

  1. #1
    Default ordering a test for a patient without symptoms
    Medical Coding Books
    A patient is seen by a gastroenterologist. Because the patient is from Asia, where there is a higher prevalence of helicobacter pylori infections and gastric cancer, the physician wants to send the patient for an H. Pylori test. This patient has no symptoms, so what dx should we use when ordering the test? Would we use 041.86 - Helicobacter Pylori Infection, even though we are not sure the patient has this dx?

  2. #2
    Columbia, MO
    NO! Do not use a dx that the physician has not documented for the patient. In a completely asymptomatic patient with no known exposure, this would be a screening.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Totally agree - it's a screening. Probably non-covered too, at the patient's expense.

  4. #4
    I agree, and I will correct the physician/medical assistant's lab request, removing the 041.86 from the form. (I am currently trying to explain to the staff that in the absence of a definitive dx, in the office/outpatient setting, you have to code the signs or symptoms.)

    But as far as screening dx are concerned - I am having difficulty locating an appropriate code, I did try to find a screening dx that would fit this scenario before I posted my question here, but I am not having much luck. Anyone have any suggestions?
    Last edited by Colliemom; 07-24-2009 at 08:21 AM.

  5. #5
    Default screening
    Maybe V74.8?

  6. #6
    Thank you! I called the pt's ins. (BCBS) and the V74.8 was accepted for use with the H. Pylori test.
    I was also told that the patient will only have to pay a $30 copay for the test. So let's hope that is correct!

    I appreciate everyone's help!
    Last edited by Colliemom; 07-24-2009 at 11:39 AM.

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