Wiki ICD 9 coding guidelines

[kumeena]

goodmorning everyone

Doctor writes abdominal pain due to gastroenteritis or diverticulosis. I feel I should code only for abd pain (789.00). But I have a answer book shows 789.00,558.9 562.10.If you have any guidelines please help me

Thank you

 

[mitchellde]

hospital inpatient coders would code the gastroenteritis and the diverticulitis, however physician coders should use only the abd pain.

 

[Walker22]

Has this patient already been diagnosed with gastroenteritis and diverticulitis in a previous encounter? If so, then you should code 789.00,558.9 562.10. If not, then just code 789.00.

 

[mitchellde]

You cannot look back to previous encounters to capture this encounter's dx. A this or that dx falls under the catergory of uncertainty which physician coders are not allowed to code. So a physician coder would code the 789.00.
In the guideline set for INPATIENT coding it states:
E.
A symptom(s) followed by contrasting/comparative diagnoses
When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses.
So the answer you have is for the inpatient coder not the physician coder.

 

[kumeena]

Thank you Everyone.

Have a nice x-mas and newyear 2010

 

[valleycoder]

im with walker22, if they have previously been diagnosed with these, then i would code out the conditions, however, i wouldnt code 789.00 since its a sign/symptom of the conditions. if they havent been diagnosed with these conditions, 789.00 is all you have.

 

[mitchellde]

I have to disagree with coding what has previously been diagnosed. If it is not documented for this encounter then we are not to go back and look at what has been diagnosed on previous encounters. This has been a long established rule. If it is documented for this encounter then by all means you may code it. But the statement of it could be this or this is not codeable for the physician or outpatient coder as I posted previous this is an inpatient guideline.

 

[kumeena]

I completely agreed with Debra. But still I am surprised with the answers in the book. (CCS-P exam prep)

 

[LTibbetts]

I also agree with Deb on this one. You can absolutely not code something from a prior visit. You can only code what is documented at that particular encounter. If it's not documented, then it wasn't done. It is the rule that we all code by. All you could use for a dx for an outpatient encounter would be the 789.xx.