Wiki Admitting DX

[AngelinaH]

Hello, I work for a hospital, doing outpatient records. I am a new coder and am having such a hard time understanding "admitting diagnosis" on minor procedure and other OP charts. For example, if a patient is coming in for pain management, and is having an epidural steriod injection would you code his lumbar canal stenosis, or the pain? Any insight on how to "get this" or where I can find guidance would be greatly appreciated!

 

[glomaxie]

Basically, anytime you have a definitive diagnosis (lumbar canal stenosis), you always want to code that---and not simply the symptom (pain)--which is obviously an integral part of the patient's diagnosis---hence the need for the epidural injection. You can also access the Official Icd-9 CM Guidelines for Coding and Reporting in your ICD9 coding book----located in the front. All your guidelines can be found there.

 

[mitchellde]

Basically, anytime you have a definitive diagnosis (lumbar canal stenosis), you always want to code that---and not simply the symptom (pain)--which is obviously an integral part of the patient's diagnosis---hence the need for the epidural injection. You can also access the Official Icd-9 CM Guidelines for Coding and Reporting in your ICD9 coding book----located in the front. All your guidelines can be found there.

As a general guideline this is true. However a chapter specific guideline will override a general. So in the guidelines under the nervous system guidelines they tell you when the reason for the encounter/service is pain management then the first listed code is the pain code which must be documented as acute or chronic (338.-) then you list also the underlying dx that is the cause of the pain.