Wiki Inpatient Physician Practice Coding

[staceyhibbert@gmail.com]

I have only been coding for about six months now and I'm seeking some clarification on physician practice coding of hospitalized patients.

It's my understanding inpatient physician practice coding is no different than physician office coding . . . you code definitive diagnoses only and if you don't have a definitive diagnosis, you code signs and symptoms. However, I have also been told it's okay to code a definitive diagnosis if the physician states (for example): "The patient's CT scan was consistent with an anoxic brain injury" or "The patient likely has an anoxic brain injury based on their CT scan".

If this was the only information you were given to base your coding off of, would you code an anoxic brain injury or would you code abnormal head CT findings?

I like for things to make sense to me. I have an extensive background in various medical fields, but I find myself trying to find where to drawn the line on what's definitive and what's not. Thanks in advance!

 

[johnpiaskowski]

Inpatient coding

There are two sides to this. The facility itself, by way of the hospital chargemaster, can bill for a definitive diagnosis even without confirmation before a patient is discharged. The performing or interpreting physician can only code signs and symptoms if it is not a yet definitive diagnosis.

 

[staceyhibbert@gmail.com]

Thanks for your response! That's my understanding as well. I work on the physician side of things (not the facility) and I'm trying to clarify where to draw the line on what's definitive and what isn't. If a physician says a diagnosis is "likely" or "consistent with", do you consider that definitive?

 

[johnpiaskowski]

Likely vs consistent

"Likely" is one of the terms grouped together with "probable, possible and rule out". "Consistent with" is acceptable to use as a definitive confirmation.

 

[chimilej]

Our auditor also confirmed to me that "consistent with" is acceptable as a definitive diagnosis. I considered "likely" as not defined so I never asked for any confirmation on that one.