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Thread: Billable Dx without Treatment Plan?

  1. #1

    Default Billable Dx without Treatment Plan?

    AAPC: Back to School
    This may sound like a dumb question, but can a provider bill a dx without a treatment plan? For example: A patient is seen and diagnosed with Dysuria, Otitis media and strep Pharyngitis. There is a plan of treatment documented for the pharyngitis (i.e. prescription meds, lab procedure results, etc), but nothing listed for the dysuria and OM. Are the billable?

    I'm pretty certain that the dx billed have to either be addressed or at least relevent to the encounter, but there is a provider questioning this.

    Any thoughts?
    Last edited by dballard2004; 12-17-2010 at 06:28 AM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  2. #2


    I am not trying to sound dumb here, I just need another take on this. Is there perhaps CMS guidance?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  3. #3
    Join Date
    Apr 2007
    Columbia, MO


    There is no rule that I am aware of except that I have read, and it may be in the coding guideliens, that we code all additional dx as long as they are managed controlled or treated during the encounter. However in this scenario All of these conditions are acute, so all were investigated and the treatment is aimed at the pharyngitis, so perhaps by treating the one condition all others will resolve as well as the physngitis is determined most basic underlying concern. So since these are all acute conditions I would code them all. As opposed to if he also mentioned the patient had HTN, and CAD, neither were treated or addressed so we would not code them.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4


    Thanks Debra! I appreciate it!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

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