Good morning Forum! I also posted this question in the billing forum, I hope someone can help me.

1. Some of our physicians use lab values instead of dictating the actual diagnosis. Like for example they will list the patient’s elevated blood pressure and bill it for Hypertension. Or they will document the patients CO2 level and bill it for Metabolic Acidosis. By the way I am in Nephrology. It is my understanding that some auditors and coders are not clinical. Where can I find it in writing that the physician can or cannot do this?

2. I am also finding that the physicians will bill for diagnosis that are listed in the HPI but does not reflect in the assessment/plan. For example, they will say in the HPI that the patient has Hypertension and bill for it, even though they are not doing anything for it. Can a physician bill for such diagnosis'?

Much appreciated!