Health Information Management

Tip: Base code on patient’s initial symptoms for undetermined diagnosis

APCs Insider, June 12, 2009

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When a physician is unable to determine a diagnosis at the time of the visit, coders should rely on the patient’s initial symptoms.
Consider the following outpatient coding rules:
  • Physician documentation should describe the patient’s condition, using terminology that includes specific diagnoses as well as symptoms, problems, or reasons related to the encounter. 
  • Coders may report chronic diseases treated on an ongoing basis as often as the patient  receives treatment and care for the conditions.
  • Code all documented conditions that coexist at the time of the encounter and that require or affect patient care, treatment, or management.
This tip was adapted from the article “The RACs are ready to go: Are you?” from the April  issue of Briefings on APCs.

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