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  1. #1
    Angry Frustrated
    Medical Coding Books

    I do all the Pro-Free coding at my hospital. What I'm struggling with is the inconsistency of the documentation.

    I hope someone can give me some advice on what they would do.

    One day a doctor will say patient has gram neg. bacteremia, and then the next day the next physician will say patient is there with COPD w/acute exacerbation.

    The next day the first doctor is saying acute resp. failure w/staph and septic shock!

    Well what happened to the gram neg. bacteremia, and why didn't the other physician mention the septic shock!??!

    Is it just me? But won't it look back if I am coding something completely different for everyday the patient is here?

  2. #2
    No they won't come back for different dx codes on one patient. The patient can have something wrong in one exam one day and another thing wrong the next day. I see this all the time in my coding. Different views can see different things in a exam as well. Hope this help a little.
    Catrina Jacobs, RCC, CPC

  3. #3
    Tacoma, WA
    Much depends on what specialty the various physicians are as well. I see this in the Pro-Fee coding when multiple specialists are seeing the same patient for different things...they all have their own opinions and diagnoses.

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