Wiki Question on diagnosis codes

[Lainie0559]

Hello,

If you have a patient your doctor admits emergently and he does an H&P with subsequent surgery:

The diagnosis he provides for the H&P is acute cholecystitis.

The diagnosis he provides for the surgery is chronic cholecystitis with calculus.

Do you:

1) Code the final diagnosis for the H&P and operative report?

or

2) Code the acute cholecystitis for the H&P and the chronic cholecystitis with calculus for the operative report?

Any input is greatly appreciated.

 

[jvanek82]

I code each encounter as documented - each document stands alone. If the doctor did an H&P and stated the patient had acute cholecystitis or even just abdominal pain, then that is what I would code from the H&P, not what was documented on another note. Once he does the surgery and makes the decision that the cholecyctitis is chronic with stones, etc., then I would code what ever is on the OP note for the OP note only.