Wiki Chief complaint vs primary diagnosis

[biker62]

Upon admission a patient comes in with nausea/vomiting (chief complaint). It is determined he has alcohol withdrawl (diagnosis). If we bill with the diagnosis, the insurance will not pay. Can we switch the primary diagnosis on the claim to the n/v?

 

[jd27]

See 2013 ICD-9 guidelines, section 2, part A (pg49 in the AMA physicians version).

Does the doctor mention both N&V and alcohol withdrawl in his report? If the diagnosis was made at a later time or date you could bill the signs & symptoms.

 

[biker62]

To clarify...Admitting diagnosis used was n/v. Determination upon discharge was diagnosis of alcohol withdrawal. Admission has been paid. Insurance is denying discharge due to primary diagnosis of alcohol withdrawal. Billing department asking if we can change it back to n/v for coverage. Thanks.

 

[KenPrescott]

I was taught to code the diagnosis, and to only code symptoms if there isn't a diagnosis. In this case, you have a diagnosis. Coding the symptoms instead of the diagnosis could be viewed as upcoding.

 

[MarcusM]

http://www.aaaai.org/Aaaai/media/Me...uide/Ch-6-Coding-and-Billing-Basics-final.pdf

Following are some general rules about choosing diagnosis codes: Page 5

3. Always code the reason why the patient sought medical advice as the primary diagnosis.
4. Do not code “probably,” “possible” or “rule-out” diagnoses. When the patient’s diagnosis
is not definite, you should code signs and symptoms until the diagnosis is definite.
5. Code the diagnosis to the highest degree of certainty by using the highest level of code.
6. When other conditions exist at the time of the patient’s encounter and they affect the
primary reason why the patient is seeking medical advice, these conditions should also be
coded.