20160831 - FREE Code Books with Exam Prep Packages | Learn More

AAPC - August DL Sale: 50% OFF
Results 1 to 7 of 7

Thread: what to code: diagnosis vs diagnosis

  1. #1
    Join Date
    Apr 2007
    Posts
    52

    Lightbulb what to code: diagnosis vs diagnosis

    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
    Join Date
    Apr 2007
    Posts
    89

    Default

    709.8

  3. #3
    Join Date
    Apr 2007
    Location
    Columbia, MO
    Posts
    12,071

    Default

    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
    Join Date
    Apr 2007
    Posts
    52

    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
    Join Date
    Apr 2007
    Location
    Stuart, Florida
    Posts
    331

    Default

    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.

    EDIT:
    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
    Join Date
    Apr 2007
    Posts
    52

    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
    Join Date
    Apr 2007
    Location
    Stuart, Florida
    Posts
    331

    Default

    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

Similar Threads

  1. Replies: 0
    Last Post: 11-11-2015, 02:50 PM
  2. Admitting diagnosis & definitive diagnosis
    By karen1123 in forum ENT/Otolaryngology
    Replies: 0
    Last Post: 08-04-2015, 05:59 PM
  3. changing diagnosis code on claim when secondary denies the diagnosis code
    By taj0257@msn.com in forum Billing/Reimbursement
    Replies: 3
    Last Post: 09-27-2013, 10:00 AM
  4. Diagnosis code for No Pathologic Diagnosis
    By benji1266 in forum Pathology & Clinical Laboratory
    Replies: 2
    Last Post: 09-02-2013, 07:00 AM
  5. History of/late effects of diagnosis vs acute injury diagnosis
    By debiwill in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 10-09-2012, 09:03 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.