Billing, Coding And Diagnosis Rules For Preventive Medicine Payments


In CPT, CPT codes determine how much you get paid because each payer will have a reimbursement amount attached to the CPT codes. So while CPT determines how much you get paid, ICD-9 codes will determine if you get paid.
If there is not a match between the diagnosis code and the CPT code that is billed, then payment may result in denial or downgrading. So it's very important that those codes make sense when you pair them up.

There are not however, any provisions in diagnosis coding for probable, possible or rule out. You must code the condition, symptom or complaint that the patient presents with. So if a patient presents with right lower quadrant pain and a missed period and nausea and first trimester bleeding, then you would code those symptoms. You would not code rule out ectopic.

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Nov 29, 2018
Donelle Holle
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Nov 29, 2018
Jill M. Young
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It's entirely appropriate however in your charting to document rule out ectopic as an impression because that as an auditor helps me understand what you're thinking was, why your medical decision making was ranked more high when you were considering an ectopic as opposed to ligament pain.

So it is entirely appropriate to document your impression in terms of a rule out or possible or probable. But for the sake of coding, it would be important to code what the symptom, condition or complaint is with respect to the patient.

Diagnosis for billing

Sometimes you may wait for a diagnosis in order to bill. However, in the case of an ectopic, if you do the work up for an ectopic and you do the history and physical exam and that's what you're thinking and everything comes back negative and it's ligament pain, you'll be hard pressed if you delayed billing that to get a level four visit on an established patient for a diagnosis of ligament pain.

So in some cases, waiting for a diagnosis may be to your advantage. In other cases, it may be best to go ahead and submit a bill based on what you know at the time of the visit because a considerable amount of time and medical decision making was involved in a visit of a woman that presents with a possible ectopic.

Use your CPT codes and diagnosis codes correctly for better reimbursement with expert healthcare webinars and events on medical coding and billing topics available at AudioEducator.

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