Chantell.Lee
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How do I code for a pt having a personal history or CAD, if that's all the information given?
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Pt Hx of CAD
- Thread starter Chantell.Lee
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mitchellde
True Blue
what is the reason for the encounter?
Chantell.Lee
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I work at a Nursing and Rehab center... This patient/resident came in for aftercare of a fractured hip but I need to code all diagnoses including history. This resident has a personal history of CAD but that is all that is says about the CAD...
Chantell.Lee
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Nevermind, I figured it out... the PT and OT wrote that the patient has a history of CAD but nothing in the Dr.'s notes... Plus, I read up on it a bit and CAD isn't ever resolved... it progresses... Thank you Debra. Our other coders didn't code it since the Dr didn't state it in his notes.
mitchellde
True Blue
Just out of curiosity thought if the reason for admission is for rehab following the hip fx then are they using the V57.1 as the first list dx code? followed by the reason for rehab ( such as gait disturbance) followed by the 905.x code for late effect of fx? I find that most of the time these do get coded as the fracture code which is incorrect so I am just curious.
Chantell.Lee
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we use v5789 then aftercare of the hip fracture... then the aftercare of the implementation of the fixation device and the other dx's follow...