Audit Risk When 1 Dx Code is Listed on Claim When Multiple Exist in Notes?

alvesey

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Cedar Rapids, IA
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My employer is having software issues and a (hopefully temporary) fix has been proposed to include only 1 Dx code per claim. Are we increasing the risk of getting audited? We are a community mental health facility and serve a high Medicare/Medicaid population.

Thank you for any assistance provided!

Annette Vesey, CPC-A
 

Chelle-Lynn

True Blue
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Modesto, CA
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Part of compliant and accurate billing is to list all billing codes that apply to the services rendered. This includes CPT, HCPCS, and DX codes. Not accurately listing all of the applicable dx codes just for the purpose of getting the claim out for billing is not compliant and can land you in a pickle if you are audited. As you know carriers look at all of the codes billed on a claim. If it is determined that one of the additional codes could have or would have affected the payment received, this could be seen as fraudulent.

If the proposed "fix" is only going to be temporary then you may want to err on the side of holding the billing until all codes can be billed accurately and completely as required under Federal and State guidelines. To knowingly bill incomplete coding just for the purpose of getting paid falls in the danger zone for fraud. Your employer would be wise to reach out to a compliance expert in your state for additional guidance and research.
 

jhendrix08

Guru
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Agreed; I think I would hold off on sending out claims. Maybe this will prompt your employer to get the issue resolved immediately. Good luck.
 
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