Wiki Inpatient Admission Diagnosis

[KoBee]

New to inpatient, I know inpatient is allowed to code for " rule out " or " suspected" .. but getting a bit confused. I have a H&P, provider is admitting the patient. Do


Patient came from ER for CHEST PAIN and no assessments have been done yet to determine exact dx.



H&P Provider documented:

# TIA VS SYNCOPAL EPISDOE MUST RULE OUT (CARDIAC ETIOLOGY RECENT + LEXISCAN)
#AKI LIKELY PRE RENAL (GFR 58 AND CR 1.07 ON 6/22/18)
#NON-AGMA (BICARB16)
#HTN
# LACTIC ACIDOSIS


Do i code the rule out dx as well as chest pain? or just chest pain and everything else provider documented. HELP!

 

[mitchellde]

The ability to code a dx documented as rule out applies only to the facility coder not the pro fee coder. The facility coder will code the admit based on the discharge summary and in the discharge summary if a dx is documented as rule out, then the facility coder is allowed to code that dx as though it exists. so if you are coding the H&P then I assume you are coding for the provider and not the facility so no you would not code the rule out as a dx.

 

[KoBee]

yes coding for the provider … so then I would could the " chest pain " ?? from what I understand in this case, correct?

 

[kathleeng]

Yes, I would code the chest pain as primary and not the rule out. Then follow with everything else.