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NLS1983

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Say I have a patient who see three different docs in the ICU.

One day one says pneumonia, gram negative w/resp failure

The next day the other doesn't mention the gram negative pneumonia, but rather just pneumonia w/resp failure.

So my question is should I code the gram-negative pna (482.83) for the first doc and pneumonia (organism unspecified) for the next doc (486)???
 
In general ...

When I rule the world, I'm going to make it mandatory that all doctors seeing a patient during the same hospital stay, use the same specificity in their diagnosis .... While I'm waiting for that day ...

You would NOT be wrong to code accurately based on what each individual doctor has documented. However, in general, I try NOT to get LESS specific with diagnosis when we're talking about a single hospital stay. Though it could be that Doc 2 hasn't looked at the lab results that Doc 1 had, it's really more likely that Doc 2 doesn't recognize the value for being specific about diagnosis (and this will be a real picnic when ICD-10 is in use.)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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