Wiki Dx versus another Dx

[Trendale]

Hello,
Is there a certain guideline to follow regarding dx versus another dx? Do we code both? (Chronic cholecystitis cholelithiasis versus gallbladder polyp). This is inpatient.

Thanks!

 

[mitchellde]

According to the guidelines for coding and reporting, as long as your are coding facility inpatient then you code both.

 

[apeck]

According to the ICD-9 after the introduction, in the 10 steps to correct coding it clearly states do not code condition that are referred to as r/o, suspected,probable or questionable, which also includes vs in my (mind) book. It has to be a clear dx or you can only code the symptoms.

 

[cheermom68]

diagnosis

For inpatient coding, you are allowed to code r/o, suspected, etc, diagnosis codes.

 

[mitchellde]

Correct this is where physician/outpatient and inpatient facility guideliens take a different path. The guidelines for coding and reporting do make this distinction. If coding for inpatient facility you may code r/o, possible, probable, suspected and this vs that as though they exist.

 

[LTibbetts]

If it were in an outpatient setting (only) you wouldn't code either vs dx. You would simply code the signs and symptoms the patient had when they came to be seen in place of a definitive dx.

 

[Trendale]

Reply to all

Thank you!
I also found information in regards to coding both for inpatient in the ICD-9 section 2 part D.