AT2728
Expert
We have begun coding for Hospitalists and I have some general diagnosis questions. I would appreciate some guidance.
Obviously, the physician dictates a new note for each visit. Do you ALWAYS code the diagnosis according to the note for each day--even if those diagnosis differ from day to day? As in, new diagnosis listed as primary, some initial admit diagnosis not mentioned in follow up notes, etc.... AND what do you in in the instance of the following...Initial H&P and day 2 follow up note by Hospitalist A state UTI with Sepsis...However, Hospitalist B notes on day 3,4, do not state this and by discharge state no evidence UTI with Sepsis ruled out by cultures. Am I to leave this off as diagnosis for Admission and follow ups since it is later stated as not found?
-Very Confused-
Obviously, the physician dictates a new note for each visit. Do you ALWAYS code the diagnosis according to the note for each day--even if those diagnosis differ from day to day? As in, new diagnosis listed as primary, some initial admit diagnosis not mentioned in follow up notes, etc.... AND what do you in in the instance of the following...Initial H&P and day 2 follow up note by Hospitalist A state UTI with Sepsis...However, Hospitalist B notes on day 3,4, do not state this and by discharge state no evidence UTI with Sepsis ruled out by cultures. Am I to leave this off as diagnosis for Admission and follow ups since it is later stated as not found?
-Very Confused-