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Tag Archives: Diagnosis

Radiology diagnosis coding

Posted on by
Hello,

I am just wondering if I can other opinions on radiology diagnosis coding.
1) If a report states that a patient got inured, and the impression states there is a sprain of a ligament, but also states there is osteoarthritis…would you just code the sprain or would you also include the osteoarthritis as the secondary?
2) If a patient has a brain MRI and is seen for dizziness/facial droop and suspected stroke, but the impression just lists atrophy and ischemia…would you code fort the atrophy and ischemia or the sypmtoms?

Just looking for input since there are different answers within our office on how people would code.

Thanks!

Medical Billing and Coding Forum

Choosing diagnosis codes for PT/OT/ST? – physician referral vs therapist’s evaluation

Posted on by
I work for a therapy company that provides services in various settings (via contracts) and am working toward my CPC certification (been in billing for years all over the specialty spectrum). I notice that some locations code encounters strictly based off of the physician’s referral. Is this an accurate practice? In reviewing the orders versus the therapist’s evaluations, I see a difference quite often as there is usually a medical diagnosis and then also a treatment diagnosis. I guess you could say I’m thoroughly confused at how therapy encounters are supposed to be coded because of what I am seeing compared to what I am studying in the books and guidelines.

Any advice or guidance would be much appreciated!

Thank you,
Lynn

Medical Billing and Coding Forum

Missing diagnosis on Op note.

Posted on by
I have operative notes that do not include any diagnosis (pre or post Op).

Being "old School" I suggested an addendum to the provider to update his note prior to billing. I was told that according to the AMA you can take the diagnosis from the H&P. That just doesn’t ring true. I might be able to see it for an ASC charge as the facility is getting the H&P as part of chart paperwork but even that is a stretch for me.

I started coding before EMRs, and live by the rules of, not documented not done and stand alone documents, but to make sure I am looking for credible references to

prove that a operative note must have a diagnosis listed. I would love to see anything that the AMA has on this topic, but I have not been able to get into the website.

Can anyone help me?

I have JCAHO Standard IM.6.30 so far.

Thank You

Medical Billing and Coding Forum

Screening Diagnosis Code

Posted on by
I work at a Urology office and we use Z12.5 (Encounter for screening for malignant neoplasm of prostate) when we draw a psa. The providers have been using this in their assessment and want to use this as a stable problem for 1 point. Can screening diagnosis codes be used at established problems if they are not really problems? Any advice would be greatly appreciated.

Medical Billing and Coding Forum

Enlarging skin lesion/cyst diagnosis

Posted on by
What 2ndary code on the LCD covers "enlarging?"

Our provider excised a sebaceous cyst that was growing, no other complications. Medicare requires a 2nd dx to justify the reason for removal. "Enlarging" is listed on the indications for removal, I just can’t pair up an appropriate dx that is covered from the LCD. I originally used L98.9 (Disorder of the skin and subcutaneous tissue, unspecified) but the scrubber kicked it back stating this dx was not on the LCD list. I have exhausted all efforts, HELP!!!

Thank you!!

Medical Billing and Coding Forum

Enlarging skin lesion/cyst diagnosis

Posted on by
What 2ndary code on the LCD covers "enlarging?"

Our provider excised a sebaceous cyst that was growing, no other complications. Medicare requires a 2nd dx to justify the reason for removal. "Enlarging" is listed on the indications for removal, I just can’t pair up an appropriate dx that is covered from the LCD. I originally used L98.9 (Disorder of the skin and subcutaneous tissue, unspecified) but the scrubber kicked it back stating this dx was not on the LCD list. I have exhausted all efforts, HELP!!!

Thank you!!

Medical Billing and Coding Forum