Wiki dx specificity help

midnightsun1369

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Hello,

Just wondering, if a diagnosis is listed under the p/a as an unspecified code and in the same note under current hospital problems it is written with more specifics, can I code to the higher specificity? see dx *** below.
I bill professional services for pts who are seen in the hospital. Also if a resident gives dx as chronic hypoxic respiratory failure and the doctor cosigns with respiratory failure, does docs dx supersede the resident dx or can I use the more specific one?
Thank you for any responses.

Assessment & Plan
Advanced sarcoidosis
***Atrial fib

Hospital Problems: Active Problems:
Acute respiratory failure with hypoxemia
Persistent atrial fibrillation
Acute on chronic diastolic congestive heart failure
Urinary tract infectious disease
Dependent edema
****Paroxysmal atrial fibrillation
Non morbid obesity due to excess calories
Acute cystitis without hematuria
ILD (interstitial lung disease)
 
Thoughts please

Please help, does anyone have any thoughts on this, suggestions of where to look.
40 some views and no thoughts, not very encouraging.
 
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