Wiki Additional Conditions

[heatherwinters]

I am looking for official guidance on billing for additonal icd-9 codes. I often see where providers list problems in their assessment only (example: using 250.00 then ordering an A1C) but did not list Diabetes in HPI or exam as an issue for that day. If a provider only lists a condition in the assessment portion of the note, as long as there is an associated plan do you give credit and allow the provider to report it? I had been told in the past it must also be listed in history or exam for it to be a billable DX. Thanks

 

[lmoura]

additional conditions

As long as the physician clearly documents the condition under the assessment and plan of their chart note then they can code for it. They can not code for a condition if it is only listed in the HPI or past history list and not documented in their assessment.

A patient may be seeing a physician for one condition and during the course of the exam the physician my find they another condition that needs to be addressed and treated so it wouldn't necessarily be listed in the HPI.

Hope this helps.

Lynn Moura, CPC