Page 2 of 3 FirstFirst 123 LastLast
Results 11 to 20 of 21

Coding "Probable" diagnosis

  1. #11
    Location
    Columbia, MO
    Posts
    12,843
    Default
    Medical Coding Books
    Physician coding may never code a possible diagnosis, they may code only confirmed diagnosis or signs and symptoms. As far as a resolved dx then it will depend on what it is. If the patient is returning for an infection and it is documented as resolved at this encounter then we code the infection since that is why the patient is returning and it not deemed resolved until after exam. However for other conditions such as post surgical we code a follow up code from the V67.xx category or an aftercare code such as a V54.x or V58.xx.

    Debra A. Mitchell, MSPH, CPC-H

  2. Default
    Quote Originally Posted by mitchellde View Post
    Physician coding may never code a possible diagnosis, they may code only confirmed diagnosis or signs and symptoms. As far as a resolved dx then it will depend on what it is. If the patient is returning for an infection and it is documented as resolved at this encounter then we code the infection since that is why the patient is returning and it not deemed resolved until after exam. However for other conditions such as post surgical we code a follow up code from the V67.xx category or an aftercare code such as a V54.x or V58.xx.
    Thank you Debra so much for your reply..

    Facility coding: Can bill probable, rule out, etc.
    Physician coding, non-facility: Cannot bill probable, rule out, etc. code off of signs and symptoms.

    Resolved: unless continuing care, cannot bill for resolved in either the facility inpatient coding or physician coding, non facililty.

    I though just to summarize it..

  3. Default Need reassurance...
    Quote Originally Posted by dscoder74 View Post
    Thank you Debra so much for your reply..

    Facility coding: Can bill probable, rule out, etc.
    Physician coding, non-facility: Cannot bill probable, rule out, etc. code off of signs and symptoms.

    Resolved: unless continuing care, cannot bill for resolved in either the facility inpatient coding or physician coding, non facililty.

    I though just to summarize it..
    What I have stated is this accurate? I would like to hear others' opinions.

    Thank you,

  4. #14
    Location
    Columbia, MO
    Posts
    12,843
    Default
    On the surface it looks good, just remember specific documentation can always assist with answering a question. The facility rule is for inpatient coders only. Outpatient follows physician rules.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    Quote Originally Posted by mitchellde View Post
    On the surface it looks good, just remember specific documentation can always assist with answering a question. The facility rule is for inpatient coders only. Outpatient follows physician rules.
    Thanks Debra for responding again. I have been in the coding industry since 1995, the past two years I have been auditing physician hospital coding and documentation. I did not have any formal education on this so it's been a hit and miss learning about the rules. Unfortunately physicians at times can get confused on which rules apply to them. Thanks again for the reassurance...

  6. Default
    Quote Originally Posted by mitchellde View Post
    Physician coding may never code a possible diagnosis, they may code only confirmed diagnosis or signs and symptoms. As far as a resolved dx then it will depend on what it is. If the patient is returning for an infection and it is documented as resolved at this encounter then we code the infection since that is why the patient is returning and it not deemed resolved until after exam. However for other conditions such as post surgical we code a follow up code from the V67.xx category or an aftercare code such as a V54.x or V58.xx.
    "If the patient is returning for an infection and it is documented as resolved at this encounter then we code the infection since that is why the patient is returning and it not deemed resolved until after exam."

    What happens then when after the exam, the patient has no indication of an infection, do you still bill it? If the physician states in his exam that there is no indication of infection, can he still bill it?

    Thank you,

  7. #17
    Location
    Columbia, MO
    Posts
    12,843
    Default
    yes we are coding the reason for the visit which was the infection, if the patient is instructed to return yet again just to be sure then that visit gets a V67.x code for follow up following completed therapy. There is an old coding clinic on this which is where I learned, but I do not remember the year, sorry.

    Debra A. Mitchell, MSPH, CPC-H

  8. Default
    Quote Originally Posted by mitchellde View Post
    yes we are coding the reason for the visit which was the infection, if the patient is instructed to return yet again just to be sure then that visit gets a V67.x code for follow up following completed therapy. There is an old coding clinic on this which is where I learned, but I do not remember the year, sorry.
    Hi Debra,

    Thanks for the reply. I code and audit in Nephrology/Internal medicine. So let's say that the patient had acute renal failure on the previous visit and the patient comes back, the physician documents that the patients' acute renal failure has resolved, can he still bill for it?

    If the patient had hyperkalemia (elevated potassium reading) on the previous visit, the patient comes back and the labs prove that the patient no longer has it, the physician states in his documentation that the hyperkalemia has resolved. Can he bill for hyperkalemia?

    I need to know if this applies to the outpatient rules? Office and Non-facility (hospital) physician coding.

    I truely appreciate your feedback.

    Thank you,

  9. #19
    Location
    Columbia, MO
    Posts
    12,843
    Default
    no to the acute renal failure and no to the hyperkalemia, these would be follow up following treatment a V67.x code

    Debra A. Mitchell, MSPH, CPC-H

  10. Default
    Quote Originally Posted by mitchellde View Post
    no to the acute renal failure and no to the hyperkalemia, these would be follow up following treatment a V67.x code
    Fabulous! Enough said! Thank you! Have a great weekend!

Page 2 of 3 FirstFirst 123 LastLast

Similar Threads

  1. "due to" diagnosis coding
    By Mareb in forum Diagnosis Coding
    Replies: 2
    Last Post: 07-07-2015, 07:18 PM
  2. Another "due to" diagnosis coding dilemma
    By Mareb in forum Diagnosis Coding
    Replies: 1
    Last Post: 07-07-2015, 07:14 PM
  3. """Looking for on Remote coding Possition""".
    By yeima26@yahoo.com in forum Resume Postings
    Replies: 2
    Last Post: 06-15-2014, 10:13 PM
  4. "Probable BCC" ?? How to dx code?
    By Orthocoderpgu in forum Pathology & Clinical Laboratory
    Replies: 2
    Last Post: 05-10-2011, 09:03 PM
  5. Diagnosis coding for "dog ears"
    By Jensina in forum Plastic Surgery
    Replies: 3
    Last Post: 07-02-2009, 02:03 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.