Wiki newbie question

[cupcakes82]

I'm sorry for just a "duh" kind of question but I am so confused. In inpatient coding, do I code for what the patient was admitted for or do I code for other diseases first. like if someone was admitted with unstable angina but on previous exam noted to have major atheromatous involvement of the left anterior descending coronary artery, with near-total occlusion. do I code first for the angina because that is what he is admitted for?

 

[twizzle]

I'm sorry for just a "duh" kind of question but I am so confused. In inpatient coding, do I code for what the patient was admitted for or do I code for other diseases first. like if someone was admitted with unstable angina but on previous exam noted to have major atheromatous involvement of the left anterior descending coronary artery, with near-total occlusion. do I code first for the angina because that is what he is admitted for?

Are you coding for the hospital or are you coding for the physician?

 

[cupcakes82]

for the hospital

 

[twizzle]

for the hospital

If you're coding for the hospital then you would code the admitting diagnosis, which is the reason the patient was admitted, in this case angina.
In addition, you're principal diagnosis would be the diagnosis, after all work up and tests etc, that necessitated the admit.
That's what I remember from my CCA coding exam.
I'm sure someone will correct me though. Principal diagnosis and admitting diagnosis are not the same but both must be coded.

 

[mitchellde]

Yes for facility inpatient coding you will have two first listed DX codes. The first is called POA stands for present on admission. This is the condition or symptom present when the provider decided to admit, then you have the principle diagnosis , this is condition after study deemed to be the reason for the admission. Look in the coding guidelines at the very end there are a few pages devoted to coding the POA code and only certain ones are allowed.