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Determining the Admitting dx for outpatient hospital

  1. #1
    Columbia, MO
    Medical Coding Books
    Your speaking of on the UB where it has the block for admitting dx? We were always told to just put the same as the primary dx there. There is no admit. Observation is the reason for observation or in the case of an obs after surgery, you use as the admitting and primary, the reason for the surgery. This is in the coding guidelines in the outpatient portion.

    Debra A. Mitchell, MSPH, CPC-H

  2. #2
    Columbia, MO
    I see. Yes the 3M encoder will ask for admitting but be sure you have it set to the APC grouper and that should go away. If not talk to the IT dept. But that is how we dealt with it. It was auto set to the DRG grouper but when we did outpatient coding we had to exit the program and then rest it to the APC grouper, when we did the issue of entering the admitting dx went away. As far the signs and symptoms, you should be able to tell from the documentation, for instance a pt has chest pain and SOB but after study the doc says the patient has no cardivascular issue they have gerd, then you do not code any of the symptoms. If you have a specific issue I can help you better.

    Debra A. Mitchell, MSPH, CPC-H

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