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Coding labs

  1. #1
    Default Coding labs
    Medical Coding Books
    I am debating with myself and I can't find it in the guidelines. It's been a long day.

    If patient presents for an office visit and labs are drawn and processed with results available BEFORE patient leaves that visit, would I rightfully code the reason the lab was ordered or would I code the outcome of the lab?
    (example- pt presents with a sore throat in walk in, so a strep test is ordered, comes back positive)do I code sore throat or strep?I am 99% sure I would not code them both?

  2. #2
    My opinion is to code what you know at the end of the visit. If they leave with a diagnosis of strep, that's what i would code. If you do not have a definitive at the end of the visit, code the reason for the visit - sore throat.
    Anna Weaver, CPC, CPMA, CEMC
    Associate Auditor

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