admitting dx

monimrtin

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I have an ER doctor that has given me a dx with the word "apparently" in front of it. I am wondering what the coding community has to say about this word. I know that we do not code the dx with possible, questionable or suspected in front of it but have never came across apparently in front of a dx before. Thanks for any help that is given.
 

monimrtin

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Pt was code blue and cpr was in progress. dr is telling me that family called ems when pt apparently had a heart attack. no ROS was available per dr's note.
 

kissie

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I wouldn't code it myself. I would code the signs and symptoms that the provider has documented in his exam. Also if there is any radiology reports that have any findings you can add those diagnosis's.
 
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