tci General Surgery Coding Alert - 2024 Issue Q3

Reader Questions: Know Who’s Responsible for Final Dx

Question: Who is responsible for the final diagnosis used for an office/ outpatient evaluation and management (E/M) visit? If a coder is reviewing documentation prior to the charge being sent and notices a diagnosis error, should the coder update the diagnosis, or is this the responsibility of the provider? AAPC Forum Participant Answer: While the provider is responsible for all claims submitted under their name, the answer to this question varies based on your employer. Some providers refuse to allow anyone to change their codes, while some have a query system where the diagnosis code must be sent back...

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