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Help! Superbill and dx listing

  1. #1
    Durham, NC
    Default Help! Superbill and dx listing
    Medical Coding Books
    The office is using an electronic system. I am finding superbills with 15 dx listed.
    Some of them are not mentioned in the chart. Should they be removed?

    Patient being seen for paranoia, but COPD is listed with the superbill.
    Can I remove it?

  2. #2
    Columbia, MO
    code only what is documented in the progress note as the acute condition, or the definitive dx after study, plus any chronic conditions that were managed controlled or treated in the encounter and any comorbid conditions documented in the note. Anything else does not exist or is inmaterial for this claim.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Our EMR system would "carry" diagnoses over from previous visits so all of that patients diagnoses would come to the superbill. We had to contact the EMR system to remove that wonderful feature so that the providers would have to go through and select the diagnoses for each visit. -Just thought that bit of info might be helpful for the future

  4. #4
    Do get them to remove the feature that carries the last Dx used onto the next visit. Sometimes things get billed out incorrectly due to that feature.

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