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Thread: Billable Dx W/O Treatment Plan?

  1. #1

    Default Billable Dx W/O Treatment Plan?

    AAPC: Back to School
    This may sound like a dumb question (as most of mine usually are!), 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?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  2. #2


    Any CMS guidance?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

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