Forum - Questions & Answers
Surgical dx
I am new to doing surgical coding. Am I suppose to use the pre-op dx, the post-op dx, or both when I am submitting the charge for the actual surgery?
surgical dx
I was taught to first use the preop diagnosis and then any postop diagnosis secondary when billing the surgeries.
diagnosis
When a patient presents for an outpatient procedure or ambulatory surgery, the reason for the procedure or surgery is the first-listed diagnosis, unless the preoperative diagnosis and the postoperative diagnosis are different. If this happens, then the postoperative diagnosis is coded.
this also applies to radiology
If I order a CXR in a patient with cough and I write "Cough" on the requisition, and the xray shows pneumonia, the radiologist codes the bill as pneumonia, not cough.