AAPC - Back to school
Results 1 to 5 of 5

Thread: Billed Dx vs Documented Dx

  1. #1

    Default Billed Dx vs Documented Dx

    AAPC: Back to School
    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
    Join Date
    Apr 2007


    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. #3


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

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

  4. #4
    Join Date
    Apr 2007
    New Delhi, India


    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. #5


    ...did not know that.


Similar Threads

  1. No p.e. documented
    By cshelton1956@comcast.net in forum E/M
    Replies: 3
    Last Post: 04-24-2014, 06:43 AM
  2. E&M visit billed no exam documented
    By dgerry in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 11-26-2012, 03:23 PM
  3. Where is it documented that you need to document?
    By swebco in forum Compliance General Discussion
    Replies: 2
    Last Post: 04-21-2011, 11:27 AM
  4. Documented "Admission" Done on Day After Hospital-Billed Admission
    By Belinda Frisch in forum Medicare Regulations
    Replies: 8
    Last Post: 05-04-2009, 07:52 AM
  5. Replies: 1
    Last Post: 04-24-2008, 08:36 AM

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?


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.