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Help with diagnosis code

  1. #1
    Default Help with diagnosis code
    Medical Coding Books
    I am not sure how to code the diagnosis for this consult:

    Patient was admitted to hospital with cough, SOB & interstitial lung disease post bone marrow tx. There is an issue of conrast CT that has been requested for evaluation of bronchiolitis and our nephrologist was consulted to evaluate for possible risk of contrast acute renal failure.

    Since patient does not actually have acute renal failure, can I code the cough & SOB, even though the nephrologist is not treating this???

    Thanks in advance for any help!!

  2. #2
    I work for a pathology group, so the specialty is different, but in our world, when there is not a definitive diagnosis we code from signs/symptoms, even though signs/symptoms may not justify the surgery, if it's all we have, it's what we have to go with.
    Patient has SOA and CP but ends up having a colonoscopy for suspected neoplasm, which turns out to be unremarkable. Guess what their diagnosis is? Yup! SOA & CP!

  3. Default diagnosis code
    Yes, use the signs & symptoms since you do not have a definitive diagnosis.

    LaSeille Willard, CPC

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