I am in a quandary right now. I was taught that you do not code anything that is not documented in the encounter note. (except chronic conditions etc that have been established and are under ongoing treatment). With this being said, the office I worked for was getting a lot of kickback for using the ‘unspecified’ codes (ex: D51.9, E78.00 etc.) and as a result they wanted to use the other specified codes (D51.8 vs D51.9).

My question is – can we do that? Here is an example:

PT comes in for a B12 shot for "Vitamin b12 def, unspecified" (word for word) as noted on the encounter. We were told to bill as "other specified B12 def" as this would pay and the other would not. Usually I would query the physician for a more accurate diagnosis but a lot of the time there WAS no more specific diagnosis, especially in these cases. Also, asking them to go back and change their diagnosis so we could bill and get paid seemed unethical. This isn’t a case of there being a more accurate diagnosis available, but changing the diagnosis on the claim.

I am relatively new, so I am curious as to whether we could do this. I refused to until I got clarification but I haven’t found any specific documentation on it. Can someone help me out or point me in the right direction? Thank you!