tci E/M Coding Alert - 2014 Issue 1

Diagnosis Coding: Scour the Documentation for a Solid Diagnosis When Your Provider Forgets to Pick One

When in doubt, go back to your provider for details. At some point, a superbill will cross your desk with no diagnosis code or diagnosis notes listed. When your provider forgets to add a diagnosis, that doesn’t mean you can’t bill the encounter. All you need to do is review the documentation to determine the appropriate diagnosis code you should assign to the claim. Sticking to the following expert tips can help you successfully find the best ICD-9 codes for your physician’s claims — without too much headache on your part. Open the Notes When You...

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