Wiki 2nd request-could really use some advice!

[AR2728]

Previously posted on Diagnosis Forum:

We have begun coding for Hospitalists and I have some general diagnosis questions. I would appreciate some guidance.

Obviously, the physician dictates a new note for each visit. Do you ALWAYS code the diagnosis according to the note for each day--even if those diagnosis differ from day to day? As in, new diagnosis listed as primary, some initial admit diagnosis not mentioned in follow up notes, etc.... AND what do you in in the instance of the following...Initial H&P and day 2 follow up note by Hospitalist A state UTI with Sepsis...However, Hospitalist B notes on day 3,4, do not state this and by discharge state no evidence UTI with Sepsis ruled out by cultures. Am I to leave this off as diagnosis for Admission and follow ups since it is later stated as not found?

-Very Confused-

 

[00029754]

If sepsis is ruled out do not code it. UTI most likely resolved with treatment so it should be coded.

 

[gailmc]

The one question I can help you with is that the progress note needs to stand alone when coding for pro-fee services. So, yes, you always code the diagnosis codes listed for that particular day unless the provider references another progress note, even if they differ. If no reference, use the diagnosis codes listed for that day. It reflects the thinking the provider was doing on the specific day. You may want to query your provider if the diagnosis change from day to day does not make logical sense from a clinical perspective.

 

[Thumper72]

I also do billing and coding for Hospitalists and although this might not be a lot of help if you look in SEction II of the ICD-9 Guidelines, it may help you in deciding which codes to use and when. Currently I code off of each Hospitalist on a daily basis a majority of the time as long as there is supporting documentation.