Wiki Inpatient resolved dx

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janinehubbard

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Ephrata, WA
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I was wondering if you code a diagnosis on an inpatient claim if it is stated in the discharge summary that it is resolved? Treatment for this diagnosis was given to the patient. It was stated by other physicians during as a dx that patient had. This is for the facility.
 
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Yes, this is addressed in the ICD-10 guidelines for inpatient coding. We code any condition that was present on admission and was treated, even if it's resolved by the time of discharge.
 
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janinehubbard said:
I was wondering if you code a diagnosis on an inpatient claim if it is stated in the discharge summary that it is resolved? Treatment for this diagnosis was given to the patient. It was stated by other physicians during as a dx that patient had. This is for the facility.
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Yes, but still need to validate if that diagnosis meets the criteria for additional diagnosis which affect patient care in terms of requiring:
  • clinical evaluation; or
  • therapeutic treatment; or
  • diagnostic procedures; or
  • extended length of hospital stay; or
  • increased nursing care and/or monitoring.
If there is any conflicting or unclear documentation, you can query the physician especially if it will affect the DRG.

Thank you!
 
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