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Dx Coding for Anesthesia Pro-fee Billing

3labs

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In billing for the professional services of an anesthesiologist, if the documented diagnosis on the anesthesia record is different from both the OP report and/or the pathology report, which diagnosis can be coded for billing?

If using a diagnosis other than what the anesthesiologist documented, do they need to clarify prior to claim submission?

Any official references or documents to support your reply would be greatly appreciated!
 
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