Screening vs Diagnostic Tests: Getting It Wrong Can Cost You

Betsy Nicoletti, MS


January 20, 2020

The Coding Expert Answers Your Questions

Betsy Nicoletti, MS, a nationally recognized coding expert, will take your coding questions via email and provide guidance on how to code properly to maximize reimbursement. Have a question about coding? Send it here.

In this column, Nicoletti explains the difference between billing for screening versus for diagnostic testing, as well as the use of new principal care management codes for healthcare professionals.

Coding Labs Tied to Annual Physical Exams

Question: We are a primary care practice, and we often order labs for our patients prior to their annual physical exam. We're having a disagreement about what diagnosis code to use for the lab tests. My coder tells me that if the patient has high cholesterol on the problem list, I can't use a screening diagnosis. Is she right?

Answer: Your coder is right. A patient who has a known diagnosis is no longer being screened for the diagnosis. The purpose of the test is for management of the condition.

The fact that it is ordered at the time of an annual physical doesn't change the selection of the diagnosis code. This needs to be explained to patients, as I'm sure you know, because the patient may think that anything done at, or ordered, at the time of a preventive visit is considered "preventive." However, tests used to diagnose a condition based on signs or symptoms, or used to manage an existing condition, are not considered screening.

In your example, for a patient without a known cholesterol disorder, use Z13.220 (encounter for screening for lipoid disorders). If using the test to monitor and manage, use a code from category E78 (disorders of lipoprotein metabolism and other lipidemias).

The general guidelines in the ICD-10-CM book explain the difference between screening and diagnostic tests: "Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (e.g., screening mammogram)."

This is difficult for patients to accept. Their expectation is that their lab tests ordered at the time of an annual physical will be part of their "free" service. But, following coding guidelines, do not use a screening diagnosis code if the patient has the condition.

Getting Reimbursed for 'Principal Care Management'

Question: Will commercial payers reimburse the new codes for principal care management that CMS developed?

Answer: CMS is implementing new Healthcare Common Procedure Coding System (HCPCS) codes for principal care management in 2020. When Current Procedural Terminology (CPT), maintained by the American Medical Association (AMA), adds new codes, most payers recognize and pay for claims submitted with those codes.


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