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What is the difference between a "billing Dx" and a "medical Dx"?

  1. Default What is the difference between a "billing Dx" and a "medical Dx"?
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    Has anyone heard of a difference between a "billing diagnosis" - which tells you "why" you saw someone, vs assigning a "medical diagnosis"? That the medical diagnosis determined will not necessarily be the same diagnosis used for billing purposes? I would appreciate your comments. Thanks!!

  2. #2
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    I have never really heard it called that but when I taught ICD-9 classes one of the things I always told the attendees was just because the provider assessed a diagnosis doesn't mean you will find it in the book exactly as stated.

    ICD-9 has a lot of "other specified" codes, which means the doctor knows what it is and has assigned it but there is no code in the book for that specific condition.

    This is the only scenario I am aware of where it may look like different diagnosis was billed than was documented.

    Of course I did have a strange situation with one particular insurance carrier where they wouldn't pay for a procedure based on the specific cancer diagnosis, they wanted a more generic one. Which goes completely against ICD-9 coding guidelines but until they change their policy we have to play by their rules.

    Laura, CPC

  3. #3
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    Exclamation Billing DX vs. Medical DX
    I have never heard of a difference in the "billing" dx vs the "medical"dx. However, it has been my experience that some "billers" upon getting a denial for non covered services due to dx will "change" the diagnosis to a "billing diagnosis". In other words, if the correct diagnosis as documented by the provider is a non covered diagnosis for the procedure, lab, etc. which causes a claim to be denied, then some insurance follow up people, or billers, etc. have been known to look for a covered diagnosis and "assign" that code in order to get a claim paid. As you all know, this is unacceptable. If a diagnosis is not covered by the local or national determinations, then an ABN needs to be obtained prior to performing the service so that a patient may be billed. This is the only type of scenario that I can imagine where the "billing" dx and "medical" dx might be different. As a certified coding instructor, I always make sure that my coding students learn early on the importance of assigning only properly documented services and diagnosis. Sylvia Adamcik, CCS-P, CPC-I, CPC

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  5. #5
    Default possibility
    I wonder if this refers to the starting and ending diagnosis. Admitting Dx vs. Discharge Dx or Pre-lab vs Post-lab. For example a patient could be admitted for abdominal pain and then determined to have a hernia. Or a biopsy could be done and billed out as uncertain and when the lab comes back it is determined to be malignant.
    Of course, you should be billing the final dx, but say someone bills out an Admit the next day with only the symptoms and before the patient is determined to have a final Dx.
    Does that make sense? That's the only thing I can think of. Where did you hear this?

  6. #6
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    Quote Originally Posted by apmc View Post
    I wonder if this refers to the starting and ending diagnosis. Admitting Dx vs. Discharge Dx or Pre-lab vs Post-lab. For example a patient could be admitted for abdominal pain and then determined to have a hernia. Or a biopsy could be done and billed out as uncertain and when the lab comes back it is determined to be malignant.
    Of course, you should be billing the final dx, but say someone bills out an Admit the next day with only the symptoms and before the patient is determined to have a final Dx.
    Does that make sense? That's the only thing I can think of. Where did you hear this?
    Susan,

    Your statement sounds right, maybe thats what she means, thats the only thing that popped in my mind too.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

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