Wiki Outpatient/Observation hospital coding

[mitchellde]

Hospital outpatient follows the same coding guidelines for ICD-9 as physicians. Hospital inpatient coders have the same guidelines as well with a few minor differences. The Coding guidelines do have a section for hospital that will help you. The entire guideline set can be found at the CDC website.
I am not sure what you mean re: chest pain from the indication for a heart cath; we code either the symptom or the definitive dx. You may code a definitive dx and a symptom if the symptom is not only part of the definitive but is also an indicator of something else leading to further study. If chest pain is part of the symptom set the patient presented with then you may code it. I the patient had a diagnosis, and now chest pain is leading them to the heart cath for further workup then you may code it. If chest pain is not a symptom at the present time and the heart cath is being performed as a routine followup, yet chest pain will pay for the test, then no you may not code it. If the heart cath is being performed for followup and the patient develops chest pain which causes the test to be aborted and other treatment started then you may code it. I tried to run down all possible scenarios here, if yours is different please post additional information.

 

[mitchellde]

You code from what is documented at the time of the procedure, or indication for the procedure, or what is documented after study. So unless it is a skin excision you do not need to wait for the results you may code what you have which is the indication for the procedure, if the results are normal you still code the indication for the procedure. So if the patients symptoms were what prompted the heart cath, then that is what you may code.

 

[mitchellde]

Yes that is fine as it is the physician's statement as the indicator for the test.

 

[lnick]

ED coding supervisor

Outpatient "facility" OBS should we use 99218 thru 99220, 99234 thru 99236 & G0378 whichever applies?

Thank You