Wiki Billing 99213 with 10 Diagnosis Codes

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ashleighd

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I've come across a couple of billing slips and it has a 99213 marked, but then there are about 10+ diagnosis codes marked. Does this raise your eyebrows?
 
I am a student going into medical coding. If my responses don't make sense or not correct I apologize. Could this possibly be over-coding? It just sounds like a lot of diagnoses for a 99213. Sounds like this would be something you should bring to the attention of your supervisor if you are questioning or it sounds like you work in billing so maybe ask the person who coded the patient chart why there are so many diagnosis codes for a level 3 office visit. I can see this being done correctly if the patient maybe has several diagnoses he/she is being treated for at the time of this encounter but if you are not sure I would ask your supervisor or who ever coded the chart to look into it.
 
Read the note, does it state the provider addressed 10 or more diagnosis? Code what is managed controlled or treated, so if it is addressed by the provider, or if they order tests or adjust medications for the condition or if the condition is one that impacts another condition being treated such as HTN. If the patient past medical history is simply in a listing in a history section of the note, you should not be coding from that.
 
From an E&M auditing perspective, you'd choose only what's managed, evaluated, assessed or treated that day. However, it's likely that multiple diags meet that criteria, and certainly from a risk adjustment perspective, it's helpful to report those codes, if they are true chronic conditions impacting today's visit. But if the provider is adding diagnosis codes from past acute conditions that have already resolved, that wouldn't be appropriate.
 
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