Coding rule out diagnosis inpatient
[DOC File]Diagnosis in the Assessment Process
https://info.5y1.org/coding-rule-out-diagnosis-inpatient_1_25833c.html
Rule-out—the client meets many of the symptoms but not enough to make a diagnosis at this time; it should be considered further (e.g., rule-out major depressive disorder). Traits—this person does not meet criteria, however, he or she presents with many of the features of the diagnosis (e.g., borderline traits or cluster B traits).
[DOC File]Applying Comorbidity Measures Using VA and CMS (Medicare ...
https://info.5y1.org/coding-rule-out-diagnosis-inpatient_1_34f71f.html
So ordinarily, a common way that people deal with this is that once somebody is in an inpatient care setting, a diagnosis is appearing only when it is a major factor in dealing with the inpatient care. So you would not just put a rule out diagnosis. So seeing it once on a record is generally considered sufficient on the inpatient side.
[DOC File]Applying Comorbidity Measures Using VA and Medicare Data
https://info.5y1.org/coding-rule-out-diagnosis-inpatient_1_657e02.html
Let’s say the physician or provider is concerned about coronary heart disease and sends the patient for stress test and writes in rule-out coronary heart disease. In that situation, the coding rules state that the diagnosis should not be entered, yet we know that this happens so it is important to avoid this. These are some rules of thumb.
[DOC File]Professional Services Coding Guidelines
https://info.5y1.org/coding-rule-out-diagnosis-inpatient_1_f17815.html
Example: The diagnosis documented “rule out malignant neoplasm of the pancreas” cannot be coded, as the diagnosis is unconfirmed. The documentation indicates a mass on the pancreas. ... For inpatient coding use the 9925x series for the initial consult and subsequent hospital care codes (9923x) for all additional encounters.
[DOC File]CODING COMPLIANCE MODEL COMPLIANCE PLAN
https://info.5y1.org/coding-rule-out-diagnosis-inpatient_1_feaea5.html
12. For inpatient coding, when a diagnosis statement consists of a symptom followed by comparative or contrasting diagnoses, assign codes for the symptom as well as for the diagnoses. When coding outpatient services, do not code diagnoses documented as "probable, suspected, questionable, rule out or working diagnosis".
ADT Category Codes List
Uncertain Diagnosis – If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible” or “still to be ruled out”, or other uncertain qualifier, code the condition as if it existed, as above in Principal Diagnosis (Inpatient only).
[DOC File]New Jersey MEDICAID STATE PLAN
https://info.5y1.org/coding-rule-out-diagnosis-inpatient_1_d29472.html
(a) Effective for inpatient services with discharge dates on or after (the effective date of this rule), general acute care hospitals will be paid in accordance with the New Jersey Medicaid Diagnosis Related Groups (DRG) Reimbursement System described in this subchapter.
[DOC File]Transcript of Conference Call 5/21/09
https://info.5y1.org/coding-rule-out-diagnosis-inpatient_1_8330be.html
MR. LIBMAN: There are specific coding rules for inpatient cases, inpatient coding guidelines, and there are specific coding rules for outpatient. And one of the areas that they differ the most greatly is that in the area of uncertain diagnoses and the emergency department is considered an outpatient setting.
[DOC File]Documentation and Coding for Patient Safety Indicators
https://info.5y1.org/coding-rule-out-diagnosis-inpatient_1_7b7b0c.html
Document the outcomes of “rule out,” “consider,” and “possible” diagnoses. Identify the principal diagnosis. Include all secondary diagnoses and conditions. Expert Coding. Coders should be encouraged and empowered to focus on the quality of coding, not just productivity.
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