Hospital Inpatient Records

Question 1

When coding using the date range, which note should be coded first?

Answer 1

The discharge summary should always be coded first 

Question 2

What items are necessary to determine a valid discharge summary?

Answer 2

Admit date, discharge date and valid signature

Question 3

The discharge summary documents, hypertension with heart failure. Later, a progress note documents essential hypertension. Which hypertension code or codes should be reported for the inpatient stay?

Answer 3

I 110– each code is reported once during an inpatient stay and a more specific hypertension diagnosis exist in the discharge summary, so there’s no need to add I10 from the progress note always Code to the highest specificity possible.

Question 4

Notes in the inpatient state that like a valid signature should be skipped.

Answer 4

True, notes with a signature issue in a date range are not considered for coding 

Question 5

Intermediate care, facilities are covered facilities under Medicare:

Answer 5

False intermediate care facilities are non-covered facilities.

Question 6

What is the process for coding inpatient stays?

Answer 6

The process for coding in patient stays is to code the discharge summary first and then add other codes from other notes in the state that are new codes or that at specificity to what you’ve already recorded. Don’t miss any supported diagnoses from the other notes and code the most specific code in this situation, you should read the rest of the notes in this day while keeping the code you’ve captured in mind looking for codes that are different or more specific.