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what to code: diagnosis vs diagnosis

  1. #1
    Lightbulb what to code: diagnosis vs diagnosis
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    I work in dermatology. The doctors tend to document for example Eczema vs Psoriasis.
    The doctors state that they aren't sure exactly which diagnosis is correct but it's not just a Rash. How do I code this? Thank you!

  2. #2

  3. #3
    Columbia, MO
    I agree when coding outpatient or physician you cannot code this vs that. Inpatient facility based coders will code both conditions.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Default dx vs dx
    This is an outpatient clinic. I was told that you can't code dx vs dx it's the same as coding a rule out. I was just at a Resident's training and that is what was said.

    Can anyone direct me to a website where I can print something out?

  5. #5
    Stuart, Florida
    When documentation indicates uncertainty in the diagnosis, it cannot be coded. In the case of the doctor documenting DX versus DX, neither can be coded. Instead, code signs and symptoms, to the highest degree of certainty for the encounter, until a definitive diagnosis is given.

    (This rule is not applicable to inpatient admissions to short-term, acute, long-term care and psychiatric hospital.)

    Hope this helps.

    Looks like I was a bit late but, if you have your ICD-9 book handy, I believe all of them have the Official Guidelines printed in them. Most have the guidelines printed in the front of the book, but I hear some are printed in the back. Anyway, the rules for coding probable diagnoses is there for you. Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services, I. "Uncertain diagnosis"
    Last edited by ohn0disaster; 06-23-2011 at 10:20 AM.
    Vanessa Mier, CPC

  6. #6
    Default dx vs dx
    I knew I saw that somewhere! Thank you. I hope the doctor accepts this, it doesn't state "vs" in the description.

    Does the doctor need to repeat the symptoms in the Assessment for me to code it or can I use the symptoms from the HPI? (I believe the doctor needs to repeat it in the Assessment)

  7. #7
    Stuart, Florida
    Yes, it should be indicated in the final impression/assessment. If you see that it was written throughout the body of the note, but the doc forgot to add it to his final impression, I would take the documentation back to the doctor for clarification, if that is even a possibility. That is how I was taught, at least.

    Though "vs" is not specifically stated, they do directly state "or other similar terms indicating uncertainty". They couldn't possibly list them all, as that would make for an extremely wordy guideline and an even heavier book!
    Vanessa Mier, CPC

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