Wiki Billed Dx vs Documented Dx

Vrdurden

Networker
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Location
Tavares, FL
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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
 
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