Wiki Exam Prep_Provider Query

[willblanding@gmail.com]

Dear all, I need help on this. Is answer B correct, and why? Please advise, thank you so much!
A patient's discharge summary does not contain a diagnosis that is documented by the anesthesiologist in a preoperative evaluation and that the diagnosis would impact MS-DRG assignment. The coder finds no evidence that the diagnosis contradicts documentation from the attending physician. The coder should:

a. Code only from the discharge diagnosis
b. Code the diagnosis reflected on the anesthesia preoperative evaluation
c. Code the most severe symptom
d. Query the attending physician regarding the clinical significance of that diagnosis

 

[amyjph]

Who are you supposed to be coding for, the attending? Is this an inpatient coding scenario (I assume yes if they are talking DRGs)?

 

[willblanding@gmail.com]

Hi Amy, yes you are correct. It's an inpatient coding scenario. Could you please advise further? Thank you. : )

 

[amyjph]

I think it's B too. I am not an inpatient coder though.
Could be D too.
But, I think you can use the anesthesia record, not just the discharge summary when IP.

 

[willblanding@gmail.com]

Well acknowledged. Thank you Amy, you rock! : )