Wiki Inpatient coding

[AmyMardesen]

I'm very new to this so I hope I make sense and that I'm doing this correctly. If a patient comes in with an issue, say respiratory failure, chronic, and stays inpatient for a few days, on the discharge the provider has listed diagnoses that were not an issue during this inpatient stay. Are those to be coded? Do they even need these mentioned on the discharge summary? Example: patient was inpatient in August with MDD, severe, with psychotic features. During this stay in October, I'm sure she still has major depression, but if it was not noted as severe during this stay, would that be correct coding? Or if during her August stay she had hallucinations but NOT during this stay, should hallucinations be mentioned again?? Thank you in advance for any guidance on this ~

 

[grothrock]

I'm very new to this so I hope I make sense and that I'm doing this correctly. If a patient comes in with an issue, say respiratory failure, chronic, and stays inpatient for a few days, on the discharge the provider has listed diagnoses that were not an issue during this inpatient stay. Are those to be coded? Do they even need these mentioned on the discharge summary? Example: patient was inpatient in August with MDD, severe, with psychotic features. During this stay in October, I'm sure she still has major depression, but if it was not noted as severe during this stay, would that be correct coding? Or if during her August stay she had hallucinations but NOT during this stay, should hallucinations be mentioned again?? Thank you in advance for any guidance on this ~

Unless the provider documented a plan or assessment on how these conditions were addressed or treated I wouldn't code them as secondary, you could query the provider to amend the record with additional supporting documentation if needed.
Section III. Reporting Additional Diagnoses
GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES
For reporting purposes, the definition for "other diagnoses" is interpreted as additional clinically significant conditions that affect patient care in terms of requiring:
clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring.

 

[AmyMardesen]

Unless the provider documented a plan or assessment on how these conditions were addressed or treated I wouldn't code them as secondary, you could query the provider to amend the record with additional supporting documentation if needed.
Section III. Reporting Additional Diagnoses
GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES
For reporting purposes, the definition for "other diagnoses" is interpreted as additional clinically significant conditions that affect patient care in terms of requiring:
clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring.

Thank you so very much! I greatly appreciate your response to this!