Wiki Urgent: Inpatient Principal Diag Question

[jsd123]

OOPS! In my last post I guess i didn't make it clear this was a hospital admission and therefore an inpatient coding situation--sorry!

Anyway, here is my delimma:

Pt comes in w/brain mets (from prior breast Ca, treated and "cured" many years ago); her symptoms are neuro as you would expect (memory issues & headaches)

On work-up an intracranial hemorrhage is seen on CT & MRI

Soooo...those symptoms that caused pt presentation to ER & admission to hospital could have been caused by either the mets or the hemorrhage!

Is CA or intracranial hemorrhage the principal?

Also--do you include the V code for pers hx of CA as a secondary?

Thanks!

 

[drsnpatil]

Networker

OOPS! In my last post I guess i didn't make it clear this was a hospital admission and therefore an inpatient coding situation--sorry!

Anyway, here is my delimma:

Pt comes in w/brain mets (from prior breast Ca, treated and "cured" many years ago); her symptoms are neuro as you would expect (memory issues & headaches)

On work-up an intracranial hemorrhage is seen on CT & MRI

Soooo...those symptoms that caused pt presentation to ER & admission to hospital could have been caused by either the mets or the hemorrhage!

Is CA or intracranial hemorrhage the principal?

Also--do you include the V code for pers hx of CA as a secondary?

Thanks!

I code this templet as Intracranial hemorrhage as principal diagnosis and all relevant situation as secondary one.

Hope others also share there ideas on same!!

 

[LTibbetts]

Based on what you've documented, I would also go with the hemorrhage as the primary dx. Now you can always query the doc if you think that the mets, not the hemorrhage, is the main reason for the admission, but I seriously doubt it. Docs are usually pretty straightforward about their cancer dx's and what is secondary to the cancer or cancer treatment, etc. Either way, unless the doc specifically states that the reason for admission is due to the mets and not the hemorrhage, than I would stick with the hemorrhage as the primary being that the hemorrhage is what was found after work-up. (just my opinion, of course)