Wiki Diagnosis not documented on DOS


North Tonawanda, NY
Best answers
We are doing profee billing for hospital care services.

  • For the initial hospital care (99221-99223) visit documentation states that patient came into the hospital and was found to have an Acute Kidney Injury secondary to Rhabdomyolysis. Coders reported N17.9 (AKI) for this encounter, not M62.82 (Rhabdomyolysis). Is this correct?
  • For the subsequent hospital care (99231-99233) visit for the same patient, the day after; documentation does not document AKI anywhere in the record, but does say the patient has rhabdomyolysis. Coders again reported N17.9 (AKI) for this encounter, not M62.82 (Rhabdomyolysis). Is this correct?

Coders say that, for profee billing, in the inpatient setting, even if a diagnosis is not documented on that specific date of service, they may look back at the previous dates of service (same length of stay) to pull out the diagnosis that was previous coded during that hospital stay. Is this correct?

My recommendation was to code M62.82, not N17.9, for both encounters. Although I would be ok with coding both on the initial and just M62.82 on the subsequent.

Any advice here?
You should only code what is documented on that DOS. so for the initial E/M both of your dx codes, i would say, is correct, and the second subsequent E/M visit i would only code the rhabdomyolysis since that is the only dx documented on that DOS, whether or not the patient has AKI in the past. You do not want to go to previous records and find a dx because the provider is Evaluating and Managing the patient on that specific DOS. if an E/M is being billed the documentation should contain an assessment and plan for that E/M visit and should have a dx. If the document for that DOS does not have a dx then i would say to query the physician. Going back to old DOS is not the way to code.