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coding pneumonia

  1. Default coding pneumonia
    Medical Coding Books
    provider dx pneumonia, no labs, no xrays, can pneumonia be coded or just signs/symptoms. Pt has cough, fever, chills, sob especially when coughing.

    ???????

  2. #2
    Location
    Evansville Indiana
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    Default pneumonia
    If the provider gave the dx as pneumonia, that is what I would code.

  3. #3
    Location
    Columbia, MO
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    12,844
    Default
    Quote Originally Posted by samyjw View Post
    provider dx pneumonia, no labs, no xrays, can pneumonia be coded or just signs/symptoms. Pt has cough, fever, chills, sob especially when coughing.

    ???????
    A physician is allowed to diagnose infective conditions based on the clinical presentation of the patient with no confirming studies being performed. So if he states pneumonia then it is, same with UTI, Otitis media, Sepsis, Strep.

    Debra A. Mitchell, MSPH, CPC-H

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