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International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10) Coding Topics

Coding Preventative Diagnostic Tests
Coding Preventative Clinical Laboratory Tests

Coding Preventative Diagnostic Tests

If I provide a diagnostic test for preventative reasons to a Medicare beneficiary that reveals an abnormal result, do I have to list an ICD-10 code that indicates the service was for screening purposes?

No. Medicare defines screening as providing a service in the absence of illness, injury, or symptoms. You should code based on the findings and not the intent. If you perform a preventative service and the results are normal, then you should use an ICD-10 code that indicates screening. However, if you perform a preventative service that reveals an abnormal result, then you should list the ICD-10 code that illustrates the findings.

The process your practice uses for processing claims determines how you should proceed when this situation arises. It is likely that you will list a diagnosis code when you provide the preventative service. If you list a screening diagnosis at the time you provide the service only to later discover an abnormal result and you have yet to submit the claim, you should simply change the diagnosis from a screening code to a code that represents the abnormal findings. If you have already submitted the claim, you should wait for Medicare to deny payment for the claim because of its screening diagnosis (only a few screening services, such as pap smears and mammograms are payable under the Medicare statute). Once the claim has been denied, you should resubmit it with the diagnosis indicative of the findings, a condition that is likely payable by Medicare. This practice prevents the beneficiary from being saddled with the burden of paying the full costs for services that uncover an illness or condition.

Coding Preventative Clinical Laboratory Tests

Must I use a screening ICD-10 code when I order laboratory tests in advance of a comprehensive preventive physical examination?

No. The diagnosis code you use indicates your findings not intent. If you order clinical laboratory tests prior to a patient's scheduled comprehensive physical examination and the results are abnormal, you should list the most specific diagnosis code for the condition indicated by the test results at the time of the face-to-face comprehensive preventive physical examination. If the tests come back normal, however, you should list a screening ICD-10 code.

Some physician prefer to have a patient undergo lab tests before a preventive examination so they can discuss the results, and, if necessary, initiate treatment during the face-to-face visit. If you use this approach, you should have the patient sign an advanced beneficiary notification (ABN), or waiver, form, so you have documentation that the patient is aware that he or she is liable if Medicare does not cover the test(s).

This approach is only effective if you can wait to list a diagnosis code until you receive the test results. Since you must provide a diagnosis code with the test order when you refer tests to a reference laboratory, use a screening diagnosis code when you order screening tests that are performed by a reference lab in advance of a preventive physical examination.

Last updated: 12/17/2015