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diagnosis coding physician inpatient

  1. #1
    Default diagnosis coding physician inpatient
    Medical Coding Books
    I am looking for information on how to handle this. Our doctors see patients at the hospital and use hospital rounding cards to submit their charges.
    The cards have more than one day attached to them, but only 1 place for diagnosis codes.
    So if a patient is seen one day with Acute CHF, HTN, and DMII and then later develops another condition of say pneumonia, the rounding card will list all 4 diagnosis codes on it for all days that the provider saw the patient.
    Now if I am reviewing notes on day 3, the notes might only list the first 3 diagnoses, but the actual bill will have all 4.
    Would you consider this incorrect?

    Thanks

  2. #2
    Location
    Columbia, MO
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    Default
    Coding must come from a review of the note, so yes it is incorrect if the claim contains codes not supported by the encounter note for that date of encounter.

    Debra A. Mitchell, MSPH, CPC-H

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