Coding for MELD dx?

JDHumenay

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Hi there fellow coders!
I have a note where the MD left off his "assessment". In the plan, the MD states: "We will continue her on IV antibiotics and sterilization of the abdominal fldui. Her MELD score is 31 and requires liver transplant evaluation."
There is some debate on how to code this. The coder selected an ICD-9 off the Laboratory data documented in the note. It states: "Total fluid white count is 19,000 with 87% neutrophils consistent with spontaneous bacterial peritonitis." So the coder selected 567.23.
Once reviewed by a second coder, they felt that 572.8 was more appropriate.
It's my personal opinion that 567.23 seems most appropriate, since there are many different diseases that could have prompted the MELD test, and the MD doesn't rule out any of them - so "other specified" doesn't seem accurate.
Can you folks weigh in (with any supporting documentation) on this one?
Thanks!
 

tpontillo

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Just need to be clear here, are you looking at the lab report or did the doctor write that diagnosis in his report? If you are looking at the lab report, I was always told not to code of off that. The doctor has to make the diagnosis. If the doctor did put the diagnosis in his report I would go with the 567.23
 

JDHumenay

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The sections in "quotations" above were found in the physician's note. The MD did not denote an assessment in the note. That's where the question came up for the most accurate icd-9 that can be assigned based on what is currently documented.
Thanks!
 
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