We all know that some physicians tend to overload dictation with unecessary ICD-9 codes thinking that it would help the level of visit. I advise my physicians if it is not applicable to the visit do not bill or code it. I need a consensus on how other coders view this scenario.

Medical Decision Making

Provider "DICTATED" 4 STABLE chronic illness, only "BILLS" for 2 = 2 problem points

Level of risk = 2 or more stable chronic illnesses

Data reviewed = 0


Medical Complexity - LOW
Exam - Detailed
= 99213


Medical Complexity - Moderate
Exam - Detailed
= 99214 "For "dictating" the four problem points even though billed for only two

I work in a coding facility that I am not able to "kick back" the billing slip for the provider to bill diagnosis that are missed but supported by dictation.

Any insight would be greatly appreciated!