Wiki Coding refusals & future orders with annual physical

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MeanderingMichigander

MeanderingMichigander

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Local Chapter Officer
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Patient is being seen for an annual physical. Z00.00


BUT... they refused the offer of a colonoscopy

AND... the provider is ordering a mammogram.


To include or not to include.... Z53.20 for the refusal AND/OR Z12.31 for the mammogram order.


Discuss. :confused:


Thanx!!
 
no you would code neither of those. You do not code for a procedure not carried out as no procedure was order or on verge of being performed. A screen can be refused by the patient, the fall out of not having a recommended screening is between the patient and their payer. You do not use screening codes for ordering a screening you code the screening dx code when the actual screening procedure is performed. this is in the coding guidelines as well.
 
mitchellde said:
no you would code neither of those. You do not code for a procedure not carried out as no procedure was order or on verge of being performed. A screen can be refused by the patient, the fall out of not having a recommended screening is between the patient and their payer. You do not use screening codes for ordering a screening you code the screening dx code when the actual screening procedure is performed. this is in the coding guidelines as well.
Click to expand...

Thanx. That's how I read & understood it, but you know how sometimes it's just nice to have someone else confirm things? So -- I appreciate it! :cool:
 
Need some direction

Can someone point me in the direction where I can find documentation stating that you don't use a screeningcode when ordering a diagnostic test? I have been looking for it and can't locate. Any help would be greatly appreciated.
Thanks in advance.

Carol Hodge, CPC, CDEO, CCC, CEMC
 
Maybe this will help:
from the coding guidelines:
5)Screening
The 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. In these cases, the sign or symptom is used to explain the reason for the test.
The Z code indicates that a screening exam is planned. A procedure code is required to confirm that the screening was performed.
 
mitchellde said:
no you would code neither of those. You do not code for a procedure not carried out as no procedure was order or on verge of being performed. A screen can be refused by the patient, the fall out of not having a recommended screening is between the patient and their payer. You do not use screening codes for ordering a screening you code the screening dx code when the actual screening procedure is performed. this is in the coding guidelines as well.
Click to expand...
Hi mitchellde,

"You do not use screening codes for ordering a screening you code the screening dx code when the actual screening procedure is performed. this is in the coding guidelines as well."

What coding guideline are you referring to? Can you please provide a reference?

Appreciate it!
 
mitchellde said:
Maybe this will help:
from the coding guidelines:
5)Screening
The 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. In these cases, the sign or symptom is used to explain the reason for the test.
The Z code indicates that a screening exam is planned. A procedure code is required to confirm that the screening was performed.
Click to expand...
"The Z code indicates that a screening exam is planned" Isn't the ordering of the procedure considered planning?. I'm still looking for a reference since many practices link screening codes to appropriate orders for procedures.

I you find any other reference, I'd appreciate it. Thank you!
 
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