What dx's can be used?

[jdibble]

If anyone can answer this it would be great! I code for various surgeons in our practice and never had this issue before. I have a Plastics that I code surgeries for. I get a copy of the OP note and have to code from this. The doctor has been doing breast reductions and in her report she states only the following:

PREOP DIAGNOSIS: Bilateral breast hypertrophy.

POSTOP DIAGNOSIS: Bilateral breast hypertrophy.

PROCEDURE PERFORMED: Bilateral breast reduction.

So I send the billing off for the breast reduction with the dx of Breast Hypertrophy. No specimen was sent to pathology so there is no path report for any further dx. Now her office staff is calling me because they had to get approval for the surgery so it was not considered cosmetic and states that I need to include a dx for back pain or neck pain, or whatever dx she used to get it approved. I told her I can only code with the dx I was given on the OP report. She wants to send me the dx she used for the approval even though it is not listed on the OP report. Is it appropriate to add codes from another source if it is not stated in the OP report that I am coding from? If the insurance requests the report for review, the dx billed will not be there, so is this acceptable?

I appreciate all responses!

Thanks,

[mitchellde]

No it is not acceptable to use a dx not documented in the operative note. If the payer needs additional information then previous office notes stating the back pain could be use as the basis for the medical necessity.

[jdibble]

Thanks Debra. That is what I had thought, but I needed another opinion to support what I tell the doctor and her staff.