Author Topic: Coding question?  (Read 1248 times)


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Coding question?
« on: December 02, 2015, 08:54:26 AM »
Question regarding Dx coding.  I was asked this question by a friend not sure about the answer but I would say the FCA conference auditor is correct.. please confirm for me..  thanks!

We was told conflicting information regarding coding for all diseases and post-surg codes.  On a new patient are we supposed to code for things like cardiovascular ds, tachycardia, etc if we are not treating the patient for these things?  We were told previously that doing that will show cohesive treatment, but at the FCA conference we were told by an auditor that we should not put dx codes unless that particular diagnosis affects the treatment we are administering to the patient.  Can you enlighten us please? 


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Re: Coding question?
« Reply #1 on: December 02, 2015, 12:38:46 PM »
The way I was taught was that you only dx on the claim what the patient is being seen for/treated for at that particular visit. You can certainly include as many dx's in the treatment note as the patient has, but what goes on the claim is limited to what the patient is being seen for that day.


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Re: Coding question?
« Reply #2 on: December 02, 2015, 03:08:15 PM »
I agree with Kristin, however if you are seeing the patient for the first time and taking the history, then I would think those dxs would be included on the claim as well since they are being addressed in that the patient is making the provider aware of them so that the provider can effectively treat them.
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Re: Coding question?
« Reply #3 on: December 03, 2015, 06:18:21 AM »
Hi Karen. You can code those other issues as "Personal Hx of" codes as secondary or tertiary just to document that the patient has had those health problems. Your primary Dx code is always what is being presented at that session/visit. Hope that helps.


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Re: Coding question?
« Reply #4 on: December 03, 2015, 11:20:12 PM »
Also keep in mind that when it comes to E/M codes submitted on a CMS-1500 form, you are limited to four dx's, be it electronic or paper.