Wiki ICD-10 Coding for Inpatient Consultants

Sarahjax

Guest
Messages
2
Location
Land O Lakes, FL
Best answers
0
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?
 
The inpatient guidelines apply only to the coding of hospital inpatient claims, not to physician claims for services performed while the patient is in the hospital. Professional claims (whether the patient is at an inpatient, outpatient, office or other location) would be coded according to the outpatient guidelines, so you would not code an possible, unconfirmed or uncertain diagnosis on any physician claim.

For physician claims, all of the practices I've worked with would only assign codes for the conditions that the provider has documented they are addressing or considering in the particular service that is being coded. Coders would not code from other parts of the hospital record or pull diagnoses or other information from other notes that are not related to the specific service or visit being billed.
 
Top