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dx codes

Marilyn Posted Wed 12th of March, 2014 18:05:29 PM

I am now receiving superbills with multiple diagnosis codes not knowing which is primary, secondary, etc that the patient was seen for because it's not indicated on the superbill. I don't see the patient(s) records. Can I just go ahead and bill just going down the page or do I need to know which is primary, secondary, etc.?

SuperCoder Answered Thu 13th of March, 2014 17:02:58 PM

The first diagnosis code reported should be the chief reason the patient was being seen by that physician.

The second diagnosis code reported should be the chief medical reason the preoperative clearance is being sought. If no medical condition is found by the internist performing the examination, then a second diagnosis code can be assigned based on the reason for the surgery.

Most payers will not recognize V codes as primary diagnoses that substantiate medical necessity.

What line does the secondary diagnosis go on? The question also indicated that, only one diagnosis code can be linked to any given procedure. Actually, the HCFA 1500 form allows for four diagnosis codes to be reported. Any one of those diagnoses, or all four, or two or three of the four, can be linked to any one CPT code reported on the 1500 form.

According to HCFA, in column 24E, titled Diagnosis Code, when multiple services are performed you should enter the primary reference number for each service, either a 1, 2, 3 or 4 (depending on the CPT code that the diagnosis is linked to and whether it is the first, second, third, or fourth code listed). This means that if you performed an E/M service that is coded as 99204, you could enter four diagnoses codes in Box 21, and reference all four codes in Box 24E by writing, A1, 2, 3, 4.

Although CMS indicates that there is no requirement to sequence in order of the plan of care, it just makes sense that your clinical documentation will support the diagnoses selected if the clinician/coder considers the plan of care when sequencing diagnosis codes

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