TEST 1 PART 2 Flashcards
Note that ____________ means the MD is aware of the problem and is evaluating it in terms of testing, consultations, and close clinical observation of the patient’s conditions.
Clinical evaluation
No particular order is mandated for sequencing other diagnoses; the more ___________ ones should be sequenced early in the list.
Significant
If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded; however, some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy.
EXAMPLE: A patient is admitted with acute MI; the physician notes that the patient is status post cholecystectomy and had been hospitalized one year earlier for pneumonia. At discharge, the physician documents the acute MI as the principal diagnosis and also includes status post cholecystectomy and status post pneumonia as other, or secondary, diagnoses.
Only the acute MI is reported as the other conditions have no bearing on the current episode of care
Previous conditions
____________ may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment
History codes (categories Z80-Z87)
_____________ such as hypertension, Parkinson’s disease, COPD, and diabetes are systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation.
Some ___________ affect the patient for the rest of his or her life; such conditions almost always require some form of continuous clinical evaluation or monitoring during hospitalization and therefore, should be coded.
EXAMPLE: A patient is admitted following a hip fracture, and a diagnosis of Parkinson’s disease is noted in the history and physical examination. Nursing notes indicate that the patient required additional care because of the Parkinson’s disease
Both diagnoses are reported
Chronic conditions
_______________ (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance.
If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the ____________ should be added.
Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.
EXAMPLE: A low potassium level treated with IV or oral potassium is clinically significant and should be brought to the attention of the physician if no related diagnosis has been recorded.
Abnormal findings
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.
General Coding Guideline – Provider Documentation
The terms _______ and _______ are often used interchangeably in describing outpatient service
contacts and, therefore, appear together in these guidelines without distinguishing one from the other.
Encounter and Visit
The _______________ definition of principal diagnosis does not apply to hospital-based outpatient services and provider-based office visits.
Uniform Hospital Discharge Data Set (UHDDS)
Coding guidelines for ________ diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.
Inconclusive diagnoses
