New to inpatient, I know inpatient is allowed to code for " rule out " or " suspected" .. but getting a bit confused. I have a H&P, provider is admitting the patient. Do
Patient came from ER for CHEST PAIN and no assessments have been done yet to determine exact dx.
H&P Provider documented:
# TIA VS SYNCOPAL EPISDOE MUST RULE OUT (CARDIAC ETIOLOGY RECENT + LEXISCAN)
#AKI LIKELY PRE RENAL (GFR 58 AND CR 1.07 ON 6/22/18)
#NON-AGMA (BICARB16)
#HTN
# LACTIC ACIDOSIS
Do i code the rule out dx as well as chest pain? or just chest pain and everything else provider documented. HELP!
Patient came from ER for CHEST PAIN and no assessments have been done yet to determine exact dx.
H&P Provider documented:
# TIA VS SYNCOPAL EPISDOE MUST RULE OUT (CARDIAC ETIOLOGY RECENT + LEXISCAN)
#AKI LIKELY PRE RENAL (GFR 58 AND CR 1.07 ON 6/22/18)
#NON-AGMA (BICARB16)
#HTN
# LACTIC ACIDOSIS
Do i code the rule out dx as well as chest pain? or just chest pain and everything else provider documented. HELP!