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