Hepatitis B screening performed on [Date] for [Patient Name], [Date of Birth].  Reason for screening includes [reason for screening e.g., routine health maintenance, occupational exposure, family history of Hepatitis B, intravenous drug use, pre-operative testing, pregnancy, abnormal liver function tests].  Patient reports [patient-reported symptoms or lack thereof e.g., asymptomatic, fatigue, nausea, abdominal pain, jaundice].  Physical examination reveals [relevant findings e.g., normal abdominal exam, hepatomegaly, jaundice].  Laboratory testing ordered includes Hepatitis B surface antigen (HBsAg), Hepatitis B surface antibody (anti-HBs), Hepatitis B core antibody (anti-HBc), and if indicated, Hepatitis B e antigen (HBeAg) and Hepatitis B viral DNA (HBV DNA).  Results of prior Hepatitis B testing, if available, are [prior test results and dates].  Patient education provided regarding Hepatitis B transmission, prevention, vaccination, and the significance of the test results.  Plan includes follow-up on [date] to review laboratory results and discuss management options if necessary. Differential diagnosis includes other causes of abnormal liver function tests, such as hepatitis A, hepatitis C, non-alcoholic fatty liver disease, and autoimmune hepatitis.  ICD-10 code Z13.89 encounter for screening for other specified viral diseases will be used if screening results are negative.  Appropriate ICD-10 codes will be used to document positive findings or diagnoses, such as B18.0 for chronic viral hepatitis B with delta-agent and B18.1 for chronic viral hepatitis B without delta-agent. CPT codes for the ordered lab tests will be 87340 for HBsAg, 86706 for anti-HBs, 86705 for anti-HBc, 87341 for HBeAg, and 87516 for HBV DNA quantitative if performed.  Medical necessity for testing documented based on patient risk factors and clinical presentation.