Wiki E&M with multiple DX

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c.cannon

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Is there any publication that I can be referred that indicates you can or should utilize more than 1 DX code with the E&M code on the claim form?

Or is there a specific reference that indicates only utilize 1 Dx per CPT code?
 
E/M selection is based on documentation, ROS, PFSH and physical exam. The number of diagnosis factors in when coming to your level for a part of the MDM portion of the chart note. Do you have anyone to show you how to level E/M codes?
 
E&M with multiple Dx

It's not an issue of the level of care, its the issue Dx codes when more than one present in the documentation that is associated with a given E&M code.

EMR system includes all DX associated with a given E&M. Provider advised that only 1 dx is necessary for an E&M code.

Example: DX 216.5/709.09 (since self limited) - 2 needed to support 99213
DX of 702.0 with CPT 17000
DX of 238.2 with CPT 11100

Provider advised to code only 1 dx above with 99213 on the claim is necessary.
 
c.cannon said:
It's not an issue of the level of care, its the issue Dx codes when more than one present in the documentation that is associated with a given E&M code.

EMR system includes all DX associated with a given E&M. Provider advised that only 1 dx is necessary for an E&M code.

Example: DX 216.5/709.09 (since self limited) - 2 needed to support 99213
DX of 702.0 with CPT 17000
DX of 238.2 with CPT 11100

Provider advised to code only 1 dx above with 99213 on the claim is necessary.
Click to expand...

There's no limit to how many dx codes per an E&M although 4 per a claim line item is the max and you can only fit 12 onto one claim form... You code whatever the doctor documented. If the patient came in with 10 problems and the doctor diagnosed all 10 problems then you code all 10 problems onto the claim form. What I would usually do is choose 4 of which ever is more serious of the 10 and append those four dx's to a level of E&M since you can't throw all ten in one line item..

You have to code whatever the doctor treated, you can't code random diagnosis if that's what your practice has been doing or just code only one of the diagnosis out of how ever many problems the provider is treating. I know of practices that just codes without looking at the documentation and rely on whatever codes the EHR generated which is very bad practice. You're coding to report what you're treating to the insurance, you can't just only code one problem if documentation shows that the doctor treated more than one problem.
 
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