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Admit and Reason for Visit Codes


On outpatient labs/x-rays, if a more definitive diagnosis is found on an x-ray and coded as principal, wouldn’t you use the diagnosis on the doctor’s order for the admit/reason for visit code? Some payers question medical necessity without it. Also it is the diagnosis on the order that is scrubbed for an ABN, not the final result on an x-ray. Does Medicare/Medicaid look at an admit/reason for visit code at all?


It is my understanding that the only time Medicare recognizes the admitting diagnosis on an outpatient claim is for an emergency room visit.  The diagnosis provided by the physician on the order for the outpatient test should be submitted as one of the final diagnoses.  While the results of a physician interpreted report may be used in the outpatient coding process, caution should be used as the coding guideline is that incidental findings on these reports should not be coded.  It may be difficult for the coder to make the distinction between an incidental finding and one that should be coded.  For outpatient ancillary coding purposes, if the provided diagnosis meets medical necessity, there is no need to refer to the interpreted report for additional diagnoses.  A valid use for referring to the results of an interpreted report when coding ancillary outpatient records is if the physician has provided a rule out diagnosis that needs to be verify since we can not code a rule out diagnosis on an outpatient claim or a fracture diagnosis where the report may provide the actual site of the fracture.  

Disclaimer: All articles intended for general consumption only and not as a recommendation for a specific situation. Readers should consult an official source (AHA, AMA, etc.) or a qualified attorney for specific legal guidance.
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