Diagnosis coding for Consultation

Murkjp

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Grand Rapids, MI
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I work for a Mental Health facility that conducts outpatient assessments for Autism Spectrum Disorder. Per insurance carrier, there is also a request for a Medical evaluation. The medical staff sees the patient, providers documentation and Dx related to any medical conditions identified. They are medical providers and not screening for ASD but claims are denied by carrier due to not having ASD Dx on them. There is also no confirmed Dx of ASD at the time of encounter. Does anyone have experience with this? Should the Medical staff be putting the Dx of ASD on claim even though the patient does not have a confirmed Dx and it is not what the exam is for? Any advice would be appreciated.

Thank you
 

mitchellde

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Columbia, MO
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You do not use a dx code that is not documented as a confirmed diagnosis for the patient. If they are being sent to you as a consult then my guess is the patient has signs and symptoms indicative of ASD, there fore I would look up the symptom codes and use those. It cannot be a screening if the patient is exhibiting symptoms.
 

Munzueta

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El Paso
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I agree with mitchellde,

and keep in mind, you want to stay away of using a diagnosis just to get something pay. We as coders code based on physician documentation and their final interpretation of the conditions. If they are being seen for any symptoms of ASD (hyperactive, short attention span, aggression, unusual mood reactions) then you will focus on coding those. Only code ASD when the physician has provided a confirmed/established diagnosis of ASD.

hope this helps!
 

Tami_F

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When coding for suspected autism, I often use F94.8 (Other childhood disorders of social functioning). It depends on the documentation.
 
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