Hello Code Master coach 😁 Inpatient Coding; is coding the "probable", etc... dx. only acceptable if it is listed on the d/c summary or is it acceptable to code those dx. from any of the medical record I/P stay? TIA Mary
Mary Harper, if at discharge for an inpatient stay, the physician states that the patients diagnosis is "probable" and the services were aimed at treating the "probable" condition, then yes you can code it because that is all you have and the services were geared toward treating the "probable" condition.
@@codemastercoach6636, Thank you for clarifying! I had always been in conflict about coding "suspected", probable, etc.. unless it was on the d/c summary. I've saw where some pick up those dx. on the H&P, consults but have never felt confident about voicing my opinion to say that those can't be picked up unless it's on the d/c summary. Ive been I/P coder for almost 3 years and I still have a lot to learn but I am loving every minute 😍. Thank you for being so kind, in helping those of us who are hungry to learn!!
Probable is still not accepted in outpatient. Not many facilities have access to lab, x-ray and CT results quick enough. Only signs and symptoms should be coded until confirmed.
@@codemastercoach6636 Do you teach classes? I have been struggling to find a CCS instructor. I'm interested in taking the CCS exam. I am currently RHIT certified.
I like how you break down in brief but clear videos; these guidelines are overwhelming 😫 thank you, thank you for your dedication Master Coach😀
You are so welcome Eriselda Alvarado.
Good job 👏 thanks for sharing.
Thank you Shakibeads.
Hello Code Master coach 😁
Inpatient Coding; is coding the "probable", etc... dx. only acceptable if it is listed on the d/c summary or is it acceptable to code those dx. from any of the medical record I/P stay?
TIA
Mary
Mary Harper, if at discharge for an inpatient stay, the physician states that the patients diagnosis is "probable" and the services were aimed at treating the "probable" condition, then yes you can code it because that is all you have and the services were geared toward treating the "probable" condition.
@@codemastercoach6636,
Thank you for clarifying! I had always been in conflict about coding "suspected", probable, etc.. unless it was on the d/c summary. I've saw where some pick up those dx. on the H&P, consults but have never felt confident about voicing my opinion to say that those can't be picked up unless it's on the d/c summary. Ive been I/P coder for almost 3 years and I still have a lot to learn but I am loving every minute 😍. Thank you for being so kind, in helping those of us who are hungry to learn!!
What about the ER outpatient setting? The dr would have access to labs, xrays , CTs. Would the probable statement still not be acceptable?
Probable is still not accepted in outpatient. Not many facilities have access to lab, x-ray and CT results quick enough. Only signs and symptoms should be coded until confirmed.
@@codemastercoach6636 Do you teach classes? I have been struggling to find a CCS instructor. I'm interested in taking the CCS exam. I am currently RHIT certified.