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Primary vs Secondary diagnosis

  1. Default Primary vs Secondary diagnosis
    Medical Coding Books
    Can you use primary dx of redyalisis status if someone comes in for a vascular test and it is stated the reason for visit is arm swelling but down at the end of the report it states that the patient is renal dyalisis status?

    Thanks for your help!!

  2. #2
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    Quote Originally Posted by JCampbell View Post
    Can you use primary dx of redyalisis status if someone comes in for a vascular test and it is stated the reason for visit is arm swelling but down at the end of the report it states that the patient is renal dyalisis status?

    Thanks for your help!!
    If the chief complaint is arm swelling, and the renal dialysis isn't relevant to the cause of the swelling, code the E/M with the swelling, and renal dialysis status as secondary. The second diagnosis mentioned sounds more informative, than anything. Code the condition that was the primary focus of the visit - where most of the history, exam, and MDM pertain to.

  3. #3
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    Quote Originally Posted by JCampbell View Post
    Can you use primary dx of redyalisis status if someone comes in for a vascular test and it is stated the reason for visit is arm swelling but down at the end of the report it states that the patient is renal dyalisis status?

    Thanks for your help!!
    You may want to querie the provider a little more. Sounds as if he may have had a problem with his graft, fistula, shunt.... In that case it would fall under the complication codes. 996.xx

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