Wiki physical therapy, occupational therapy, speech therapy billing WHICH DX?

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Byhalia, MS
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Good morning, everyone. We are having trouble with which dx needs to be on the charges, medical dx or therapy diagnosis. I run into the problem of therapists not even listing the medical diagnosis on their documentation, so I feel like I cannot just capture the code when it isn't listed at all, not in HPI or anywhere. Closest I can come is I can tell which body part they are treating sometimes.

We work across three states and it seems there is not a consistency across them either. TN, MS and AR.

I was first told to use medical dx, but not all charges have that listed, so I was told to use therapy diagnosis. Another opinion is to use a mixture of both.

Any help on this is greatly appreciated!

Thank you,

Vicki
 
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