Inpatient coders almost always code for the facility, unless in a small rural area. They do not use CPT or HCPC II codes at all. They do use Volume 3 of the ICD-9 for procedures. Inpatient reimbursement is based on the first-listed or principle dx from the discharge dx. There is usually an admitting dx as well as a principle dx that may or may not match. They are allowed to code rule out, possible, probable, suspected as though it exists with the exception of HIV, avian flu, and H1N1. They cannot code from path or radiology reports. What eles do you need to know?
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