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Wiki Can we code from differential dx?

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schacon

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Does anyone know if I can code the diagnosis in the differential section of an inpatient note? Because Medi-cal only pays F code diagnosis.

Example below

DSM 5 Diagnoses:
Altered Mental Status (AMS) R41.82

Differential:
Unspecified Schizophrenia Spectrum and Other Psychotic Disorder* - F29
Amphetamine Use Disorder - F15.20
Alcohol Use Disorder - F10.20
Amphetamine-Induced Psychotic Disorder
 
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A differential diagnosis is one that the provider is considering as a possible explanation for the signs and symptoms with which the patient is presenting. I would not use these for coding purposes because these are only a list of the options that the provider is considering and will be testing for, and none of them can be considered definitive diagnosis unless the provider confirms it in another part of the documentation.
 
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