Wiki Coding for a physician in the inpatient setting - stupid question!

[iceterrors]

I'm a very new grad and have an embarrassingly stupid question...

I code for an orthopaedic physician group - when I code for their office visits and/or all services in the outpatient setting I know that I don't code for "suspected" or "possible" diagnoses.

Does that change if the physician treats a patient who has been admitted? Now that the patient is considered "inpatient" - do I now code for all suspected and possible dx's?

Thank you for your help. This is something that I should know!!!

 

[daedolos]

I'm in a similar office setting. You can only code for what your doctor's documentation shows. If the doc says "possible" or "suspected", you can't use it. It's the same as a "rule out." Also, be wary of doctors saying ligament tear when no MRI is evaluated. Then they go ahead and in the dictation, tell the patient to come back with an MRI for further evaluation.

Peace
@_*
Hope this helps.

 

[iceterrors]

Thank you! I wasn't sure if the fact that the service is now performed in an inpatient setting if that changed how I would code for the physician.
First coder job

 

[daedolos]

Me, too. AAPC forums are a good resource. Also, attend your local chapter meetings. Not only do you get CEUs, food, and knowledge but you get exposed to possible employers and managers as well.

Peace
@_*
BTW, even if the patient was seen by the doctor in a hospital, you still can't code for more than what your doctor's dictations show. However, once in a while, the doctor will not specify which side a broken finger or wrist is and I had to glean that info from our EHR. I found it in the radiology tab with the X-ray report as well as corroborating evidence on the fee ticket as well as the intake sheet. These things happen.