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Dx versus another Dx

  1. Default Dx versus another Dx
    Medical Coding Books
    Hello,
    Is there a certain guideline to follow regarding dx versus another dx? Do we code both? (Chronic cholecystitis cholelithiasis versus gallbladder polyp). This is inpatient.

    Thanks!

  2. #2
    Location
    Columbia, MO
    Posts
    12,526
    Default
    According to the guidelines for coding and reporting, as long as your are coding facility inpatient then you code both.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    St.Petersburg, Fl
    Posts
    46
    Default
    According to the ICD-9 after the introduction, in the 10 steps to correct coding it clearly states do not code condition that are referred to as r/o, suspected,probable or questionable, which also includes vs in my (mind) book. It has to be a clear dx or you can only code the symptoms.
    Alecia Peck CPC

  4. #4
    Location
    Evansville Indiana
    Posts
    451
    Smile diagnosis
    For inpatient coding, you are allowed to code r/o, suspected, etc, diagnosis codes.

  5. #5
    Location
    Columbia, MO
    Posts
    12,526
    Default
    Correct this is where physician/outpatient and inpatient facility guideliens take a different path. The guidelines for coding and reporting do make this distinction. If coding for inpatient facility you may code r/o, possible, probable, suspected and this vs that as though they exist.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Default
    If it were in an outpatient setting (only) you wouldn't code either vs dx. You would simply code the signs and symptoms the patient had when they came to be seen in place of a definitive dx.

  7. Default Reply to all
    Thank you!
    I also found information in regards to coding both for inpatient in the ICD-9 section 2 part D.

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