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Confused? ICD-10-CM

  1. #1
    Default Confused? ICD-10-CM
    Medical Coding Books
    Patient was admitted as inpatient on 02/02/2018 with a history of mental status changes, pyuria, complaining of weakness and lethargy. Within subsequent care for 10 days, new diagnosis found everyday such as encephalopathy, respiratory distress/hypoxemia, UTI, acute on CKG, CHF, Hypoalbumin, etc. How to find principal diagnosis code?

  2. #2
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    are coding for the facility or the provider?

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
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    Quote Originally Posted by mitchellde View Post
    are coding for the facility or the provider?
    This is for provider.

  4. #4
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    principle dx is something for the facility coder to code. there is a specific place on the UB for principle dx code. The physician code will code first list the dx that necessitated the visit that day, the most acute diagnosis. code also any additional diagnosis that the provider attended to on that encounter. The physician coder codes by the encounter. The facility coder codes by the entire stay. The principle dx comes from the discharge summary and can be the same as the POA or it can be different. The POA is the diagnosis that necessitated the admission, the principle dx is the diagnosis after study that required the patient remain.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    Quote Originally Posted by mitchellde View Post
    principle dx is something for the facility coder to code. there is a specific place on the UB for principle dx code. The physician code will code first list the dx that necessitated the visit that day, the most acute diagnosis. code also any additional diagnosis that the provider attended to on that encounter. The physician coder codes by the encounter. The facility coder codes by the entire stay. The principle dx comes from the discharge summary and can be the same as the POA or it can be different. The POA is the diagnosis that necessitated the admission, the principle dx is the diagnosis after study that required the patient remain.
    So, facility inpatient coder will code once patient discharge, right?

  6. #6
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    Yes.. unless it is a lengthy stay and then they may code every 30 days.

    Debra A. Mitchell, MSPH, CPC-H

  7. #7
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    Quote Originally Posted by mitchellde View Post
    Yes.. unless it is a lengthy stay and then they may code every 30 days.
    I am wondering, Inpatient coder only code for hospital setting or provider?

  8. #8
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    Inpatient facility coder

    Debra A. Mitchell, MSPH, CPC-H

  9. #9
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    I am an inpatient coder, and Debra is correct.

    We get the record for the complete length of stay the patient was in the hospital, so we generate one single claim (UB) with all the diagnosis that were treated during the stay. For our coding we go by the "principal diagnosis" as to the first diagnosis being responsible for the admission.

    Outpatient coders will code day by day, the outpatient coder will be billing for the physician services and the first listed diagnosis will be the diagnosis for the reason for the encounter in this case day-by-day basis as you will be coding each note (H&P, progress notes, consults and discharge summary).

    hope this makes sense.
    Marco Unzueta CIC, CPC
    - Medical Records Tech - Inpatient Coder
    - Outpatient Instructor
    AAPC El Paso Chapter - President

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