Need Inpatient coding clarification - ASAP

[samuels_5]

the provider states admitting diagnosis is 1. possible syncope and 2. concern for seizure disorder. The provider states discharge diagnosis 1. probable migraine variant. 2. seizure disorder unlike with 2 normal electroencephalograms 3. possible syncope as the description of her symptoms is consistent with that 3. concussion with persistent headache.

Should we keep the principal diagnosis 346.20,Variants of migraine. i have a nurse/coder suggesting the prinicpal diagnosis is 780.2.

 

[snjberry]

I know this was an ASAP but I wanted to respond. Here is what Medicare / AHIMA say about inpt coding...
In the inpatient setting, if a diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," "possible," or "rule out," the condition should be coded as if it existed or was established. The basis for this guideline are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
I would code all listed diagnosis as inpatient is the only time those are allowed regardless of possibility or actuality.

Hope this helps in the future. Here's the link to AHIMA library.

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok2_000466.hcsp?dDocName=bok2_000466

Sandi Berry CPC, CPMA

 

[mitchellde]

The guideline for possible probable suspected is for the facility coder only it is not to be used by the physician coder regardless of the fact that the patient is in the inpatient setting.. The physician coder may not code these diagnosis at all, read your coding guidelines.. I agree with the 780.2 for the physician claim