is it safe to assume that no matter the facility setting, IN patient, out PT, ER professional or technical should the "findings/diagnosis" always be listed as primary DX...as long as it relates to the reason for the visit/exam?? And can you then add any 2ndary codes that may need to be mentioned such as for example PT has a headache with a HX of diabetes and the findings are negative. would you list just 784.0, or would you code both HA and Diabetes?
Thanks In advance
I'm not
totally sure I understand what you're asking, but I'll try to get as close as I can with my answer...The main difference between assigning Dx codes for inpatient encounters versus outpatient encounters, is how differential (or "probable", "suspected", "rule-out", etc.) diagnoses are handled. As you know, when a patient has an undiagnosed problem, the majority of the doctor's efforts are focused on finding out what's causing the problem.
For Inpatient: If the doctor has an idea of what's causing the problem, you code the encounter with his theory, as though you're sure the patient already has it. Hospital services are pre-authorized for payment, including diagnostic studies; additionally, payers are charged with covering room and board, as well as 24 hour care, for the length of the patient's stay. "Time
is money", for them. It's important for payers to know what the doctor thinks is causing the patient's illness ahead of time, so they can keep pace with approving tests and treatments in a timely manner, and minimize their costs.
Outpatient is a different story, though,
In Outpatient ICD-9 coding, there is no such thing as a "suspected" diagnosis; you either have it, or you don't. Until the doctor is able to confirm their theory, or are otherwise certain of what's causing the problem, you can only code the signs and symptoms. Claims aren't paid based on the diagnosis, and doctors have more time to figure out what's causing the problem, so assigning the diagnosis that you're
most certain of takes precedence.
In my opinion, this happens because of a fear that people might seek unnecessary health treatments, trying to chase down the cure for an illness that they may not necessarily have. Patients tend to have more control over how many doctors they see, what medications they take, and what actions they perform to manage their own health when they're not admitted to the hospital, and they're also not receiving constant assessments to confirm or rule-out a suspected diagnosis as quickly as possible. To me, it seems like the act of 'giving' someone a diagnosis that they may not have (by coding it with a particular ICD-9 code), only to find out later that the doctor was mistaken, has the potential to have much more significant consequences, when the patient is not being constantly monitored by healthcare professionals, who can make adjustments immediately, when they get new information. If that is the case, then it makes sense that outpatient encounters are assigned diagnosis codes with more attention to certainty, than inpatient encounters.
Either way, if it's an outpatient encounter, you can only code what you know for sure. If the doctor's not 100% sure what's causing the problem, then all you can be certain of are the signs and symptoms that brought the patient in, to begin with.
As for the example you asked about: The patient has a HA and a Hx of diabetes, and the doctor suspects diabetes is causing the headache. After testing, it's determined that they don't have diabetes after all.
-Since it's an outpatient encounter, it doesn't really matter what the doctor suspects, for the purposes of assigning the diagnosis codes. That's especially true with this example you gave, because his theory turned out to be wrong, anyways.
-You
know that the patient has a headache,
and that they have a
history of diabetes. You
need to know if it's a
personal history (apparently, it is
possible to 'recover from' diabetes, even if it rarely happens), or if it's a
family history. Both could be relevant to treatment, and they have different codes.
-The headache is primary, and your
History of diabetes is secondary (whether personal or family; it'll be a V code - ask the doctor if it's not clear).
You don't code DM (from the 250.XX category), because that's communicating that the patient currently has DM, when they don't.
I'm sure you weren't looking for a lecture, so I'll get off my soapbox now.
Hope that helped!
