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Billable Dx W/O Treatment Plan?

  1. #1
    Location
    Overland Park, KS
    Posts
    1,166
    Default Billable Dx W/O Treatment Plan?
    Medical Coding Books
    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, CRHC, AAPC Fellow
    Coder

  2. #2
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    Any CMS guidance?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

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