Sarahjax
Guest
I am a new coder and just started doing ICD-10 coding for doctors who provide initial specialty consultations and then follow-ups to inpatients. I learned that when coding outpatient, you only code definitive dx, but when you code inpatient you code definitive dx plus possibles, suspected, rule-outs, etc as long as they are still noted on the discharge summary. We code the consults the month after they were done and see many dx that are possibles, etc. We are not coding for a patient's whole inpatient stay only our specialists who are not employed by the hospitals, so they do not write the discharge summaries.
Should we be coding the possibles, etc from the initial consults?
It has been suggested to me that we look at the last progress note from the last follow-up visit by one of our providers and only code the possibles listed on the consult if they are still listed on that final progress note, too.
What is the correct way to code in this situation?
Should we be coding the possibles, etc from the initial consults?
It has been suggested to me that we look at the last progress note from the last follow-up visit by one of our providers and only code the possibles listed on the consult if they are still listed on that final progress note, too.
What is the correct way to code in this situation?