tci Outpatient Facility Coding Alert - 2019 Issue Q3

Reader Question: Don’t Report Ordering Dx Without Addendum

Question: If you’ve got a report without a diagnosis that meets the CPT® code’s Local Coverage Determination (LCD) requirement, but the diagnosis on the order does meet the LCD requirement, can I submit the claim using the ordering diagnosis? Montana Subscriber Answer: There are a few points to unpack here. First, you should not submit a claim with a diagnosis that the provider does not document in the dictation report. If the order includes a different diagnosis than what’s included in the report’s indication, then you should send the report back for an addendum before...

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