Wiki Coding conditions with only clinical evidence

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semillhouse

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Hello,
I've been trying to find the answer to a question I've had for a little while now. I'm wondering when/what conditions you can code with only clinical symptoms. For example, I have a chart I'm working on that has C.Diff stated as a main diagnosis but never had a C.Diff test done. It was ordered, but a stool sample was never collected. The patient has signs and symptoms, was put on precautions, and was treated with antibiotics but does not have an actual positive culture. I know for some conditions like pneumonia you can code them even with a negative chest x-ray if the doctor says it's clinical, but I'm not sure which other conditions work the same way. Anyone have any thoughts? Thanks!
 
I was really hoping that someone on here could answer my question. I've asked everyone around that I can think to ask and no one can really help me out. Would you guys need more information or is this just a tricky question? Any feedback would be greatly appreciated, even if it's just that other people are having this problem too!!
 
What exactly did the provider document. If he states possible c diff then it cannot be coded. It all depends on the providers exact wording.
 
What was the chief complaint? abdominal pain, diarrhea, etc? This would be the primary diagnosis without more detail.
 
The patient was "admitted to the med/surg floor due to altered mental status, increase in weakness and complaints of diarrhea with colitis and possible Clostridium difficile." A stool for C-Diff was ordered two separate times but a sample was never collected. I was thinking that we needed a positive stool sample to code for C-Diff but some people at my job are saying that if they had signs and symptoms and were treated for it, I can code it as the main diagnosis without a positive stool. They were inpatient so I know I can code possible/probable as an established diagnosis but I'm not sure if something like this works the same way. Thanks for your feedback
 
If you are coding for the physician you cannot code a possible dx. Only the inpatient facility coder May code a possible, suspected dx as a code. You need to code symptoms only if you are coding for the physician.
 
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