Wiki Inpatient Dx with versus

[mnevins]

In the inpatient coding setting, the documentation reads possible consolidation versus atelectasis versus pleural effusion. Do you code all three dxs or just the consolidation? It would seem to me the provider is ruling out the atelectasis and pleural effusion and thus only the consolidation would be coded. Please clarify someone.

 

[FTessaBartels]

You have NO diagnosis

A diagnosis is definite. In the absence of a diagnosis, code the symptoms.

You cannot code "possible" "Potential" "rule out" "likely" etc for PROFESSIONAL (physician) coding.

You can use some of these for hospital/facility coding.

F Tessa Bartels, CPC, CEMC