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Diagnosis Order

  1. Question Diagnosis Order
    Medical Coding Books
    The order you list on a claim does it have to be in the order the doctor documents in the patient chart? Example: Patient came into office for three month follow up and the doctor marks the level she/he wants to bill for and list medical diagnosis for that level, but when the doctor dictates the visit she/he primary reason for the visit was well women exam tahn she/he list all medical diagnosis. What diagnosis should we bill V70.0 with a well woman CPT or the visit level the doctor marked on her/his super bill with the medical diagnosis and V70.0 last.

  2. #2
    Location
    Columbia, MO
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    12,837
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    The codeing guidelines coupled with the documentation dictates how we code the claim, regardless of how the physician list the dx. A V70.0 is first listed only alowed. I the visit was a well woman then the dx code is a V72.31 and possible a code for vaginal screening ( if the patient has no cervix), and a code, for the absence of cervixand or uterus, plus possibly a code for HPV screening. Then any other comorbid or prexisting conditions, such as HTN, or diabetes. The CPT code will be a prevent visit level or the G and the Q code depending on payer. Most providers do not know the coding guidelines, as a coder we need to know and follow these.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Stuart, Florida
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    331
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    You list it as he addresses it in his dictated note, as that will be the documentation shown in the patient's chart. The doctor could check off a bunch of DXs that the patient does, in fact, have but that the doctor does not address in that DOS. Also, just because the doctor believes that he should be paid for a 99215 does not mean that he really should. That's where the coder comes in to make that final decision as to what should really be coded from what the documentation shows. I hope that answers your question and doesn't sound confusing.
    Vanessa Mier, CPC

  4. #4
    Location
    Columbia, MO
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    12,837
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    Quote Originally Posted by ohn0disaster View Post
    You list it as he addresses it in his dictated note, as that will be the documentation shown in the patient's chart. The doctor could check off a bunch of DXs that the patient does, in fact, have but that the doctor does not address in that DOS. Also, just because the doctor believes that he should be paid for a 99215 does not mean that he really should. That's where the coder comes in to make that final decision as to what should really be coded from what the documentation shows. I hope that answers your question and doesn't sound confusing.
    Just keep in mind coding guidelines for certain conditions might not go along with how he lists it in the note such as an ulcerative condition of the foot link then to diabetes, even though he addresses the ulcer first, the diabetes is the first listed code.

    Debra A. Mitchell, MSPH, CPC-H

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