Wiki Dx clarification

[midnightsun1369]

Hello

I am a new coder and would appreciate clarification on a dx.

Doctor see's pt in hospital as professional provider. 1 day he states dx to be bullous emphysema (492.0) and then the next day he states dx is Diffuse severe emphysema (492.8). Do I continue to bill each different dx listed on each note or can I bill the 492.0 because that is more specific and has been stated as dx on the previous day and pt is in hospital?

Thank you.

 

[emcee101]

Code specificity

Since each day is a separate encounter and coded/billed separately for professional services, each day should be coded to the highest specificity that the documentation allows regardless of what is documented on other dates of service. Maybe there are clinical findings that are not documented or that you are not aware of that caused the provider to change his wording of the diagnosis. You can only code whta is documented in the exam and not assume that since it is stated on a previous day that it holds true the next day even when it is not documneted.

 

[midnightsun1369]

Thank you. That's what I initially thought but then started questioning my self because pt was in hospital.