Wiki Diagnosis for inpatient visit

[lhoot]

Good Morning,

I have what might be a somewhat simple question, but I’m stuck in an inpatient thought process and just want to make sure I’m on the right path. Does the physician billing for his visits during an inpatient stay use diagnosis codes pertaining to the patient’s conditions at the time of the visit or diagnosis codes relative to the inpatient admission? For example, patient is admitted for stroke with hemiplegia. At some point during the hospital stay and patient is not currently having the the stroke, the physician sees the patient. Would stroke with residual hemiplegia be coded as a current diagnosis using I63.- codes or would hemiplegia following cerebral infarction be coded using I69.- codes? Again, this pertains to coding for the physician visit and not coding for the facility for the whole stay.

Thanks,
Laura

 

[lhoot]

For the physician code by signs and symptoms unless the physician during the time visiting patient found the definitive diagnosis is hemiplegia following cerebral infarction I69.35.
Physician/Professional cannot code for suspect, probable, rule out, etc..

Thanks so much for the sanity check.