As for IP Guidelines, UHDDS and this situation, actually it is Coding Clinic that says to sequence CAD before the Angina. To my knowledge, that doesn't have anything to do with whether it is OP or IP. Likewise, it would largely depend on the services as to what you're coding. Remember, in OP environments, each encounter (and document) must stand on its own.
Occasionally you may get an Observation note that requires one diagnosis and a surgery by the same physician (later along) that says something more specific.
I'm not sure this helps, but it doesn't seem to me the auditor is using IP guidelines, because I've read this recommendation in Coding Clinic: CAD is listed first.
In relation to the Heart cath, shouldn't that be reported with the post-procedural diagnoses, regardless of the presenting?
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join