Forum - Questions & Answers
Diagnosis Codes
Our physician is a GI, and I am wondering, when he does a consult on a patient and lists all of the patient's diagnoses, should we list any diagnoses for which he isn't treating the patient on the claim; i.e., hypertension, COPD, diabetes, etc, or should we only be listing diagnoses that relate to the reason he is evaluating the patient?
re: Diagnosis Codes
If you look in the front of the ICD-9 (or ICD-10) book, it gives instructions about reporting outpatient services, which physicians are, in detail.
Report first condition for which patient sees physician
If known dx , do not code symptoms. If no known dx, code symptoms
Code underlying conditions which affect treatment. "Can't do procedure until cleared by PCP" then code the dx that needs assessing by PCP. If underlying condition doesn't affect GI tx, do not code.