Results 1 to 3 of 3

What dx's can be used?

  1. #1
    Location
    Daytona Beach, FL
    Posts
    752
    Default What dx's can be used?
    Medical Coding Books
    If anyone can answer this it would be great! I code for various surgeons in our practice and never had this issue before. I have a Plastics that I code surgeries for. I get a copy of the OP note and have to code from this. The doctor has been doing breast reductions and in her report she states only the following:

    PREOP DIAGNOSIS: Bilateral breast hypertrophy.

    POSTOP DIAGNOSIS: Bilateral breast hypertrophy.

    PROCEDURE PERFORMED: Bilateral breast reduction.

    So I send the billing off for the breast reduction with the dx of Breast Hypertrophy. No specimen was sent to pathology so there is no path report for any further dx. Now her office staff is calling me because they had to get approval for the surgery so it was not considered cosmetic and states that I need to include a dx for back pain or neck pain, or whatever dx she used to get it approved. I told her I can only code with the dx I was given on the OP report. She wants to send me the dx she used for the approval even though it is not listed on the OP report. Is it appropriate to add codes from another source if it is not stated in the OP report that I am coding from? If the insurance requests the report for review, the dx billed will not be there, so is this acceptable?

    I appreciate all responses!

    Thanks,
    Jodi Dibble, CPC

  2. #2
    Location
    Columbia, MO
    Posts
    12,941
    Default
    No it is not acceptable to use a dx not documented in the operative note. If the payer needs additional information then previous office notes stating the back pain could be use as the basis for the medical necessity.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Daytona Beach, FL
    Posts
    752
    Default
    Thanks Debra. That is what I had thought, but I needed another opinion to support what I tell the doctor and her staff.
    Jodi Dibble, CPC

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.