Forum - Questions & Answers
DX coding...
Patient comes into our office (hem/onc office) and we are seeing them for their primary dx of 185 (mal neoplasm of prostate). Patient comes in today for a sick call- fatigue and n/v. Normally I would audit the note and put the prim dx as fatigue, second dx n/v and third is the cancer dx. My question is- shouldn't we be putting their cancer dx (in this situtation) on the claim ALL the time regardless of the other "sick" dxs they are here for?
dx coding
I would say yes as long as you be consistance or visit can just be realted to primary sick complaint as long as the sick visit is noted as a sick visit aside from the Ca diag.
I'm not so sure
It depends if the cancer diagnosis was considered by the doctor in their thought process. If the cancer was 3 years ago and you are doing surveillance visits and the patient comes in with food poisoning, i would not list the cancer as a diagnosis. If they came in 2 days after chemo or with bone pain and blood in urine, then the cancer is a pertinent diagnosis and should be listed