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annual with problems

Susan Posted Thu 14th of January, 2016 13:23:05 PM

Is it appropriate to use the with problems dx code if you do not bill a problem visit with the annual? My doctors list every dx possible even if they have only reviewed the condition. Sometimes order lab or ultrasound but not a significant amount of documentation. Or they use the without problems dx and list other dx codes.

SuperCoder Answered Fri 15th of January, 2016 06:44:49 AM


If the patient case requires multiple codes to express the patient’s diagnosis in the most complete, accurate, way possible,you can include up to 12 diagnosis codes on a single claim form and only four of those diagnosis codes can map to a specific CPT code.

When this happens, it’s crucial that you list the codes according to importance, with the first-listed (i.e., primary) code being the one that most strongly supports the medical necessity of your services.Also, the medical record documentation must indicate why the test was medically necessary if the doctor orders lab or ultrasound.


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