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Billed Dx vs Documented Dx

  1. #1
    Default Billed Dx vs Documented Dx
    Medical Coding Books
    Good Afternoon.

    I am looking for input re: which dx codes should be submitted on claim when physician lists multiple dx on note. Obviously, the primary dx should reflect reason for visit. When add'l diagnosis are also documented should all dx codes be billed?

    Example: Pt presents w/ symptoms of dry eyes only. In addtion to dry eyes physician discovers cataracts and glaucoma suspect during exam. In the final assessment he lists:

    Dry Eye Syndrome - Artificial Tears 3 x day
    Cataracts Monitor
    Glaucoma Suspect Schedule tests

    Would you submit all dx codes or only the dx that require add'l treatment? Is it acceptable to submit only the dx code that reflects the reason for the visit (Dry Eye Syndrome)?

    Vicki Durden
    Lake Eye Associates

  2. #2
    I would submit all codes
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  3. Default
    "glaucoma suspect during exam."
    "Glaucoma Suspect Schedule tests"

    This is a suspected condition and shouldn't be coded.

  4. #4
    I would code all 3 conditions because doc is doing something for each one of them. Of note, glaucoma suspect has a specific code - 365.00 and is codeable.

    Girish Dadhich, CPC

  5. Default
    ...did not know that.


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