Wiki Pre-op Diagnosis vs Post-op Diagnosis

[sheilacpc]

Please provide your coding rationale as to the correct diagnosis and ICD-10 codes based your understanding on coding conventions and guidelines for an Ambulatory Surgery encounter:

Pre-op Diagnosis: PVD with claudication of right lower extremity, hypertension, hyperlipidemia
Post-op Diagnosis: Near total occlusion of right SFA

There is a question as to whether or not ICD-10 codes should be coded for the diagnoses for "hypertension" and "hyperlipidemia" since it was not mentioned by the provider in the POST-OP diagnosis.

There is a question as to whether or not "PVD with claudication of the right lower extremity" should be coded as it was not mentioned as a POST-OP diagnosis by the provider.
Thank you.

 

[natashalage]

hello,
I am still learning everything about coding. since nobody so far answered your question, I will write mine. I read in some coding guidance that from Op note, we code only dx listed under Post-op. So in your case, I would code only '... total occlusion of right SFA." My other thought is if MD treated other conditions or they stated that they created a challenge during a procedure etc, then I would add them too. But it's not in your case.