Results 1 to 3 of 3

Using previous dx or chronic illnesses w/o doc

  1. #1
    Location
    Casa Grande & Phoenix
    Posts
    52
    Default Using previous dx or chronic illnesses w/o doc
    Exam Training Packages
    Could anyone tell me if a doctor (PCP) is allowed to diagnose previous or chronic illnesses without documentation in a follow-up visit?

    Also if they simply write these diagnosis under assessment but do not elaborate patients problem is that appropriate to use as a diagnosis on your superbill for billing?

    Example : Hypertension when the patients B/P was 124/68 with patients weight being 237 lbs.

    I appreciate any help or insight! Thank you!
    Tara Johnson, CPC

  2. #2
    Location
    San Gabriel Valley,CA
    Posts
    311
    Default
    Under ICD-9 guidelines, a diagnosis cannot be coded unless it is stated in the current visit documentation.

    Once established, a chronic condition must be restated each time it is assessed or treated. A diagnosis cannot be carried over from one visit to another.

    Hope this helps.
    Elizabeth M., CCS, CPC, ICD-10 CM/PCS
    Multi Specialty Coder/Compliance Auditor/ICD-10 Educator

  3. #3
    Location
    Casa Grande & Phoenix
    Posts
    52
    Default
    Thanks so much for your help!
    Tara Johnson, CPC

Similar Threads

  1. multiple chronic illnesses
    By cbeste in forum Family Practice
    Replies: 2
    Last Post: 08-06-2014, 03:55 PM
  2. multiple chronic illnesses
    By cbeste in forum Medical Coding General Discussion
    Replies: 6
    Last Post: 07-23-2014, 01:17 AM
  3. Status of three chronic illnesses
    By lisavalentin in forum Urology
    Replies: 4
    Last Post: 01-30-2014, 04:42 PM
  4. 1st doc can't complete DRE,2nd doc bills how?
    By uhlerclarem in forum E/M
    Replies: 1
    Last Post: 08-13-2009, 08:22 AM
  5. "chronic illnesses" question
    By Karma in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 08-06-2008, 11:15 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.