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Thread: Coding dx on fee ticket prior to getting test result

  1. #1

    Red face Coding dx on fee ticket prior to getting test result

    AAPC: Back to School
    Getting opinions from other sites for promptness on entering charges from fee tickets - any guidelines from Medicare or other plans in coding the fee tickets prior to receipt of test results ?

    Our office is committed to a 24-hour turnaround in entering charges & submitting claims. However, some docs want to hold onto fee tickets until tests are all received for a more definitive dx, especially with HCC ratio of payment based on dx.

    What are your suggestions - if a claim is submitted with signs and symptoms and the test comes in later w/a definitive dx, how would one go about getting the more definitive dx to the insurance carrier after the claim is processed and the patient has not returned for care.

    Is this something to be worked out with the insurance carriers to update the dx for the corresponding HCC payment ratio

  2. #2


    But you wouldn't code the definitive dx because THAT dx was not the reason for the test, right? We can't code "probables" or "suspects" or "most likely"...all we CAN code is the sign and or symptom. If the doc wants to do a recheck like a week later, then that's when we could code the definitive dx for that subsequent visit.

    So for example, if I come in with fatigue and poor concentration, my doc may see if I have hypothyroidism and perform a thyroid test, all my doc knows at the time of performing the test are my signs/symptoms and trying to "rule out" a thyroid disease, so that's all he/she has to go with.

    Amanda, CPC
    Anesthesia coder

  3. #3
    Join Date
    Apr 2007
    Bangor, Maine


    I agree with Amanda. If you need something in writing to show for this, use the Official Coding Guidelines, Section IV: Diagnostic Coding & Reporting Guidelines for Outpatient Services, Section L, third paragraph. You can only use the definitive dx if it is available at the time of coding.

    You can ONLY code what is doumented, 24-hour turnaround or not. Like Amanda said, a check-up after the fact could be coded with the definitive dx. Some of our providers hold up stuff for that same reason. We hold up all of our surgery charts that are waiting for a path report. That is up to the provider whether or not that is their practice. If they choose to do that, however, they must be aware that the 24-hour turnaround will not apply to them. I highly doubt that you would have any luck at all with the insurance companies on this. They would consider that just coding to get paid and that is fraud. Maybe it is the 24-hour turnaround that needs to be re-visited...Just my opinion.

  4. #4


    Leslie, awesome on those guidelines! Thanks for adding that!

    Amanda, CPC
    Anesthesia coder

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