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Wiki general inpatient coding question

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cupcakes82

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I posted this in another thread but no one has answered yet.


I recently switched from hcc coding to inpatient. I am used to coding every page of a chart and every chronic condition. When coding an inpatient chart, do I just code for what the patient came in for? or do I also code for past medical history, personal and family history codes? I think i am spending too much time looking at the charts. Please any help would be greatly appreciated :D
 
Check out Section III of the ICD-10-CM guidelines. There is some good inpatient specific information there. For example:

A. Previous conditions

If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy.
However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
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