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Wiki Referral

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cethridge1

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:)In the practice I work for, the docs are not giving a diagnosis for me to code for a patient's referral on the original charge ticket. However, the reason for the referral is written on the yellow carbon copy that I give to the people who schedule referrals. Am I correct in thinking that the reason for the referral should also be listed as a diagnosis when a claim is sent from the original copy?

Thanks, Carol E.
 
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The reason for the referral does not have to match your diagnosis on your claim. The diagnosis on your claim comes from the doctor's documentation. For example: If the patient just presents with signs and symptoms and the dr. does not have a definitive dx, then you would just code the signs and symptoms. If the doctor has a definitive dx and wants the patient to see a specialist, then you can code the dx on your claim since it is part of the doctor's assessment. I hope that makes sense.

So, no, do not assume that the reason for the referral should be the dx on your claim.

Arlene Andrew, CPC, CPC-I
SecureDocImaging
President, Pikes Peak Coders, Colorado Springs, CO
 
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