Wiki Hospital Consult Question

[tcoder5]

If an oncologist performs a consultation on day 1 of inpatient stay & the patient has acute renal failure & rectal bleeding but 2 days later, after testing, the pt has a dx of colon cancer would you code dx for symptoms for the 1st & 2nd day & colon cancer dx for 3rd day subsequent visit? Thanks for any help. I am new to hospital visit coding.

 

[mitchellde]

You would code the symptoms when that is all you know so for day 1 and 2 you did not know the patient had cancer so the symtoms are all you can code. Day 3 when the provider documents the cancer you may code the cancer. Or if you are coding for the physician on day 3 and you have the path report that states a dx of cancer then you may code the cancer, even if the physician has not yet documented it. Once you code the cancer you do not code the symptoms that were the indicators for the testing.

 

[tcoder5]

That is what I thought. Thanks for the confirmation. By any chance, do you have any other information that might be helpful for coding hospital visits? Thanks again!