Wiki Urgent Help Needed: Principal Diag Choice!

[jsd123]

Pt comes in w/brain mets (from prior breast Ca treated and "cured" many years ago); her symptoms are neuro as ytou would expect (memory issues & headaches)

HOWEVER, those symptoms trhat caused presentation & admission could also be caused by intracranial hemorrhage seen on CT/MRI (thoug due to lesions)

Is CA or intracranial hemorrhage the principal?

Also--do you include the V code for pers hx of CA as a secondary?

Thanks!

 

[dpeoples]

Pt comes in w/brain mets (from prior breast Ca treated and "cured" many years ago); her symptoms are neuro as ytou would expect (memory issues & headaches)

HOWEVER, those symptoms trhat caused presentation & admission could also be caused by intracranial hemorrhage seen on CT/MRI (thoug due to lesions)

Is CA or intracranial hemorrhage the principal?

Also--do you include the V code for pers hx of CA as a secondary?

Thanks!

IMO, it at least partially depends on the nature of the visit/encounter/appointment with your provider. For instance, if the physician seening the patient is treating the mets (gamma knife, radiation) then I would list the mets as the primary diagnosis.
If treatment or monitoring is focused on the intracranial hemorrhage, then I would sequence that diagnosis first.
If the reason for the visit is to diagnose the reason for the current symptoms, and the hemorrhage is the only recent/new diagnosis, then I would list that first.
I do think all three should be listed.

HTH