Wiki How many diagnoses codes on accounts?

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debbie jones

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I hope someone can help. I am just getting started in the medical field and have not yet started my coding career. Someone who works in a medical facility asked me this question:

Are coders only supposed to enter the first two medical/nursing diagnoses and the first two therapy diagnoses on the accounts? And are there any directives that you know of to indicate otherwise? I thought the way it used to be that Medicare payment was based on RUGs when it was DRG, and the more dx codes, the better it was.

Thank you for any help you can give me.
 
The more the better. I think the current electronic format takes up to 24.

Coders code what is documented. 20 dx codes or 1 dx code, what ever the case may be.
 
Thank you. It is a nursing and rehab facility, and I'm wondering if some of the dx codes are left off because they do not have anything to do with their treatment. Say they have hypothyroidism and they are getting therapy for something unrelated, would that be coded?

She says they have room for 17 dx codes on their form.
 
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I work in a Cancer Center and so the treatment we provide is usually for a hematology or oncology diagnosis. We code what is related to our treatment. We are not treating all of their medical conditions and sometimes overcoding can lead to denial. If a diagnosis is related to the treatment, such as, anemia of chronic disease due to rhematoid arthritis and long term use of medications then the RA dx and long term use of meds needs to be coded. Sometime we use 2 codes and sometimes we have 6 or more codes; code what gives the information about the treatment the patient is receiving and why.
 
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