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Diagnosis coding

  1. Default Diagnosis coding
    Medical Coding Books
    Can someone give me some guidance in dx coding? There is some confusion in our office regarding this. If a patient comes in for a procedure with one dx but something is found during the procedure could what was found in the procedure be used as the primary dx?

    Or does the reason for the procedure have to be used as the primary dx?

    Thanks!

  2. #2
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    Columbia, MO
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    If the reason for the procedure is screening then screening V codes must remain the first listed dx code with the finding listed as a secondary.
    If the patient presents with a symptom and a procedure is performed because of the symptoms then the coder may code what is known at the time of coding (symptoms) or may wait for the interpretation and code the finding. You do not code both unless it is clear that the symptoms and the findings are unrelated.
    An exception to this is a skin lesion excision, you must wait for a path report to code the path finding when coding a skin lesion removed by excision.

    Debra A. Mitchell, MSPH, CPC-H

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