CHAPTER FOUR

Multiple Codes

Use Multiple Codes to Support Your Claim

In addition to specificity at the code level, it may also be necessary to report multiple codes for the same visit to provide more specificity at the claim level, when clinically relevant.
Claim forms have slots for multiple ICD-10-CM codes. When reporting multiple codes, the order you place codes on the claim form is important because it gives the payer the primary reason for the visit and additional information to support your diagnosis.
- List the condition chiefly responsible for the visit (the reason you are seeing the patient) first on the claim form. This code is called the primary or treating diagnosis.
- You can also list multiple treating diagnoses, if needed. In those cases, the first-listed code should be the treating diagnosis that’s the primary focus of the visit.
- List any additional codes describing co-existing conditions, symptoms, or underlying medical conditions following the treating diagnosis. These codes are called secondary or medical diagnoses.
- These codes should only be included if they’re clearly documented in the medical record and are relevant to the patient’s condition and the reason for the visit.

CHECK YOUR UNDERSTANDING!

A patient with a medical diagnosis of vocal nodules complains of hoarseness. Their physician refers them to an SLP for evaluation, who confirms a diagnosis of dysphonia caused by the nodules.