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  1. Smile Referral
    Medical Coding Books
    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.
    Last edited by cethridge1; 10-05-2009 at 02:17 PM.

  2. #2
    What would you be using this for? Is he writing his conclusion somewhere for you to code with?

  3. #3
    Colordo Springs Pikes Peak Coders
    Default Referral
    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
    President, Pikes Peak Coders, Colorado Springs, CO

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