# final dx-can someone please help



## alices (Jan 9, 2012)

can someone please help me with this.. I have an ER chart where the Dr has well child exam as the final dx, in the Hpi it says per mom pt has decreased urine output,ed course says benign exam, he did labs and he gave fluids, the remote coder coded oliguria 788.5 as the final dx, I sent it back to her and told her she could not change the dr's dx but she could send back and ask him to clarify dx, well her auditor sent me a note saying that I was wrong and that per outpt guidelines " in the absence of a final dx you can use signs and symptoms" and since it states in the Hpi pt has decreased urine that she had coded correctly..  but the dr has a final dx he put v202 now I know insurance co's don't like that code especially on ER claims but it is a legitimate dx so I don't know why they are saying it can be changed,I sent it back to the dr before receiving this note asking him why he gave fluids if baby had normal exam  he stated he gave the fluids because mom complained of decreased urine output, so incase child was dehydrated he gave the fluids but fortunately pt was not dehydrated, so can someone please tell me is she correct? Can we change what he has in that instance? I do not feel comfortable doing this so if it is alright, can you please tell me where I can find it in writing so I can protect my self..thank you and sorry for such a long note, hopefully I explained it right..alice


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## mitchellde (Jan 9, 2012)

you cannot code a dx from the patient complaint, only from the physician exam, if he had put symptoms in the exam you could use that, however since there was a suspected condition based on Moms report then you can use either V71.x or V29.x for suspected condition not found depending on age of child.  The remote coder is incorrect and I would not let the claim go out with that dx.


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## BABS37 (Jan 9, 2012)

You can tell the remote coder and her auditor to refer to ICD-9-CM coding guidelines (Section I.B.6 and Section IV.E) they state, "Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider." He confirms his final DX as V20.2, then that's his confirmed word in my opinion.


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## mitchellde (Jan 9, 2012)

my problem here is that this was not a confirmed symptom by provider report, only the mom statement.  I have never taken a symptom as a diagnosis code from the patient report, I only go by the provider saying something like patient present with........... then if nothing else you can code those symptoms, but when symptoms lead to a healthy patient as in this case, this is what the V71.x and V29.x codes are for, suspected conditions not found.


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## BABS37 (Jan 9, 2012)

Oh I agree, we would have sent this back to the physician asking for more documentation as the patient didn't come in for a well child screening- the patient came in because the mom had a fear of a suspected condition with him not going to the bathroom adequately. Our physicians would state it as, "feared complaint not found" and we would use V65.5. They don't pay with that DX code but it's what we used. I didn't know about V29.XX, which would have been a great code to use for our peds clinic! I'm going to write that one down!


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## alices (Jan 9, 2012)

*re-final dx*

Thank you everyone I really truly appreciate the answers back, I think I know what I am doing when it comes to coding then I get other people saying I am wrong then I start doubting myself it is ridiculous, I am not always right by no means, but I am never comfortable with changing what the dr writes and I always send back if I am unsure it just amazed me that they wanted to change it without asking, so again thank you and I would not know what or to ask if I did not have this coding forum..alice


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## BABS37 (Jan 9, 2012)

Oh by no means am I always right either but I agree, I wouldn't ever change a DX either. I've been on this forum a lot lately bc I switched coding gears from interventional radiology to family practice and clinical coding to general surgery and I feel as though I'm lost. I've been on here looking for answers on my surgery stuff and at the same time, keep up on my old coding so I don't forget what I've learned in those areas. You gotta just keep on trucking!


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