Wiki Billing EMG/NCS question

[jbland]

I have a questions regarding EMG/NCS coding/billing. I am at a Neurologist office and receive referrals from PCPs for these tests. In the PCP office notes, it says the patient denies numbness and weakness. When we asked the patient about what problems she was having, she told us she was having numbness and weakness (along with pain). My question is do I use the numbness and weakness as a dx when I bill? This is the first time I have seen this happen that the patient and notes did not match. Thanks in advance for you help!

 

[Ritika]

Billing emg

Hi,
I think we should not bill the numbness and weakness as diagnosis as it is not mentioned in PCP notes and in coding we have to code according to documentation which is not present here so we will not code it, as there are chances that when PCP was examining there was no numbness and weakness but it happened gradually after sometime hence we will go according to PCP notes....Hope this will help yoy.