Part B Insider (Multispecialty) Coding Alert
Base Dx Code on Reason for Test
Question:
Answer:
You should report the reason for the exam rather than an incidental finding as your first-listed diagnosis. For example, if the ordering doctor notes swelling on the head and neck, you could report 784.2 (Swelling, mass, or lump in head and neck) and E881.0 (Fall from ladder).ICD-9 official guidelines (section IV.H) state, "List first ICD-9 for encounter/visit shown in the medical record to be chiefly responsible for the services provided." You may list additional codes describing coexisting conditions, the guidelines say.
"In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician," the guidelines state.
The guidelines are available online at www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm.
Part B Insider (Multispecialty) Coding Alert
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