Wiki DX code for inpatient setting

[rogerandpaula@mchsi.com]

Help! I am struggling with what dx code to use when my family practice Dr see's an inpatient who has had a surgical procedure such as TKR, THA, lap chole, etc. He always puts s/p TKR, THA, lap chole etc. He is only seeing patient due to monitoring medical conditions such as DM, hypertension, etc. while patient is inpatient.

Please and thank you,
Paula

 

[mitchellde]

Your physician is not the surgeon so therefore he is not rendering post operative care. You need to code only for the diagnosis your provider sees the patient for when in the inpatient setting. So if the note supports DM and or HTN then that is what you code.

 

[rogerandpaula@mchsi.com]

But at times he has no other dx listed, just s/p TKA, s/p THR, etc. Then I have no idea what to put. Thanks for your response.

Paula

 

[mitchellde]

If post operative care is transfered to hm then use the Z code for aftercare. If not you will need to see the note to see why the visit was necessary.