Results 1 to 3 of 3

Admission and Discharge diagnosis

  1. #1
    Default Admission and Discharge diagnosis
    Medical Coding Books
    We code admission diagnosis from admitting H & P and other hospital days pt has and discharge with diagnosis codes from discharge note. Is this what everyone else is doing? Thanks.

  2. #2
    I, personally, read over everything first so I have all of the information but the primary dx we use is usually coming from the discharge summary and the progress notes, whichever one deems to be what got the patient admitted in the first place and takes the most amount of care. The admit dx can come from the H&P but most of what the patient was treated for will be be on prog notes and d/s.

  3. Default
    Our guidelines state that each note must stand alone. The one exception to that is on the discharge note, if a diagnosis was not dealt with sometime during the stay (including the discharge) we can leave it off (our doctors can add patient problem list to notes, which adds ALL diagnoses on the patient record).

    This can cause some inconsistency for us, as one doctor may note diabetic ckd, and another may only note diabetes, and one could say type i and another type ii, etc. all in the same patient stay.

Similar Threads

  1. Admission and Discharge
    By eleciah83 in forum E/M
    Replies: 1
    Last Post: 04-29-2015, 02:58 PM
  2. Admission/Discharge Same DOS?
    By volleyb13 in forum E/M
    Replies: 1
    Last Post: 05-24-2011, 05:58 PM
  3. Discharge then re-admission
    By brackman1 in forum Billing/Reimbursement
    Replies: 0
    Last Post: 01-20-2011, 01:06 PM
  4. admission/discharge with heart cath
    By kimwinkle in forum Cardiology
    Replies: 2
    Last Post: 03-12-2010, 08:56 AM
  5. Replies: 2
    Last Post: 04-01-2008, 04:21 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?


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.