Wiki out patient coding for hospital help

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dmolina42

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Hi everyone I am very new to this career and I need help :) . I am trying to get help in coding out patient diagnostic testing. and I am confused about the admitting dx and first listed dx here is a example if a patient comes in for chest pain and they do a stress test and the impression is cardiomegly with mirtal regurgitation what is my first listed dx ? I would code what the impression is but people are telling me to code the chest pain please help ????
 
You may code what you know at the time of coding or after study but not both. An exception to this would be skin lesion excisions where you must wait for the path report . Also if the symptom is not explained with the diagnosis then code both, in other words if the diagnosis is an incidental finding and the provider is still looking for the cause of the symptoms then you code both. Also outpatient does not have an admitting dx code, you have a principle dx. So on the claim the admitting and principle are the same.
 
debra thank you for responding I am still confused. cause the screen we use has four things dx from admitting then admitting dx then principal then secondary. so we have to enter a admitting dx and principle and if a secondary code. hope this explains better
I better understand with examples so let me see if if I can give you a few and you let me know if I am on the right track. 1. ok pt comes in to hospital and on the script from ordering doc is echocardiogram dx is chest pain. the test is done and nothing is abnormal in results then I would code the symptom chest pain correct ?
2. pt comes in for same scenario but the echo shows cardiomegly and regurtitation I would still code the chest pain as principle?
 
It sounds like your system is set to the inpatient grouper . We had that same issue until the IT department was able to allow the coder to indicate inpatient or outpatient claim. But if they cannot do this just know that admitting and principle is the same for outpatient.
Example 1 code the chest pain
Example 2 you may code either but not both, which do you have at the time of coding the claim ? Unless the provider interpreting the result indicates the dx is incidental and the chest pain still requires investigation, in that case code both.
 
when I code I have the results that was viewed by a radiologist or cardiologist. I don't deal with claim portion. once I code the encounter it goes to a billing dept and they do claim. I am just coding the encounter only hope this helps. all I see is the impression from the dx test and it will state example cardiomegaly is seen and there is mild aorta regurgitation but that is all that is stated. I hope I am not confusing you
 
dmolina42 said:
Hi everyone I am very new to this career and I need help :) . I am trying to get help in coding out patient diagnostic testing. and I am confused about the admitting dx and first listed dx here is a example if a patient comes in for chest pain and they do a stress test and the impression is cardiomegly with mirtal regurgitation what is my first listed dx ? I would code what the impression is but people are telling me to code the chest pain please help ????
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You can never code for impression of anything. So if no definitive dx. You have to code signs and symptoms. Hope this helps.
 
The impression is a dx rendered by the radiologist which can be coded by the coder in the outpatient or physician area.
Ok so if you are coding from the Radiologist or Cardiologist reading then I will say you will code the diagnosis as the finding rather than the symptom. I was thinking you were doing the entire claim and I was trying to be as generic as I could to cover all the bases. Now knowing exactly what you do makes the answer easier. Once you have the finding there is no need to code the symptom.
 
I just have one more question when you have mutilple dx in the impression how do you know what to list first or does it matter example
1. splenomegaly
2. gallbladder polyp
3. hydrophenosis

so how would I judge what would be prime


thanks again
 
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