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Urgent Help Needed: Principal Diag Choice!

  1. Default Urgent Help Needed: Principal Diag Choice!
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    Pt comes in w/brain mets (from prior breast Ca treated and "cured" many years ago); her symptoms are neuro as ytou would expect (memory issues & headaches)

    HOWEVER, those symptoms trhat caused presentation & admission could also be caused by intracranial hemorrhage seen on CT/MRI (thoug due to lesions)

    Is CA or intracranial hemorrhage the principal?

    Also--do you include the V code for pers hx of CA as a secondary?

    Thanks!

  2. #2
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    Quote Originally Posted by jsd123 View Post
    Pt comes in w/brain mets (from prior breast Ca treated and "cured" many years ago); her symptoms are neuro as ytou would expect (memory issues & headaches)

    HOWEVER, those symptoms trhat caused presentation & admission could also be caused by intracranial hemorrhage seen on CT/MRI (thoug due to lesions)

    Is CA or intracranial hemorrhage the principal?

    Also--do you include the V code for pers hx of CA as a secondary?

    Thanks!
    IMO, it at least partially depends on the nature of the visit/encounter/appointment with your provider. For instance, if the physician seening the patient is treating the mets (gamma knife, radiation) then I would list the mets as the primary diagnosis.
    If treatment or monitoring is focused on the intracranial hemorrhage, then I would sequence that diagnosis first.
    If the reason for the visit is to diagnose the reason for the current symptoms, and the hemorrhage is the only recent/new diagnosis, then I would list that first.
    I do think all three should be listed.

    HTH
    Danny L. Peoples
    CIRCC,CPC

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