I'm new to inpt coding, I have my CPC but not my CCS. I have a patient who presented to the ED with an acute onset L leg weakness. ED note states L leg weakness in addition to TIA. Patient has a history of 2 remote CVA's walks with a cane. My question is would the admitting dx be a late effect of a CVA and also, the discharge diagnosis states: Acute onset L leg weakness (resolving) and hx of CVA - no significant residual symptoms. No mention of TIA. Condition on discharge: neuro symptoms completely resolved. Would the principal diagnosis be TIA? Any help appreciated.
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Wiki Primary Diagnosis - supporting documentation
- Thread starter momo2
- Start date
natashalage
Guru
hello,
I am not an expert. here is my thought: this is ED setting; therefore, it will be ED E&M unless the pt was admitted by the same specialty, then it will become Inpatient E&M. Dx is whatever was found at the discharge- in our case- L leg weakness and hx of CVA. MD didn't link current weakness to the history of CVA; therefore, it's not sequela of the old CVA. It's acute onset, unrelated to history.
I am not an expert. here is my thought: this is ED setting; therefore, it will be ED E&M unless the pt was admitted by the same specialty, then it will become Inpatient E&M. Dx is whatever was found at the discharge- in our case- L leg weakness and hx of CVA. MD didn't link current weakness to the history of CVA; therefore, it's not sequela of the old CVA. It's acute onset, unrelated to history.
Thank you. I was concerned as the ED note states L leg weakness; TIA and the inpt coder selected TIA as the principle dx. I reviewed the official guidelines I.A.19 regarding code assignment and clinical guidelines and was wondering if just because the attending physician stated "TIA" but didn't bring it into the D/C Summary, would it be appropriate to assign as the principle dx, but my gut says no, especially b/c the D/C summary doesn't include it. Thoughts?
TThivierge
True Blue
Hi Momo2
I d code it as left side monoplegia dx I69.344 or M63.862
and dx Z86.73 for HO of CVA. If he has wheelchair or cane as abling device add dx Z99,89 . Well hope this helps you.
Lady T
I d code it as left side monoplegia dx I69.344 or M63.862
and dx Z86.73 for HO of CVA. If he has wheelchair or cane as abling device add dx Z99,89 . Well hope this helps you.Lady T
Last edited:
amyjph
True Blue
Are you coding the inpatient record or the ED (outpatient)? The emergency department is not inpatient even though they may use the words admit.
Admitting diagnosis and/or principal diagnosis coding is different for inpatient versus outpatient.
I'm coding for after the patient presents to the ED, then is admitted as inpatient.