I am seeking some information on what others are doing or what should be done for this situation.

Physician will document for conditions that are addressed such as Neck Pain (M54.2) and Paresthesia (R20.2).
Then a Point of Care test will be done that does not have any diagnosis associated with it. For instance, note will have the two codes given then have a POC Hepatitis C Screen and POC HIV Screen done.

1. for these tests would you only put the M54.2 and R20.2 on these line items. Since this is exactly what the provider signed off on.
2. query the provider for a diagnosis for these tests.
3. coder add the screening codes for these tests.
4. other??