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Discharge Diagnosis-Professional Service

Kerri Posted Fri 28th of July, 2017 17:28:17 PM
For discharge services 99238, 99239, 99217 for the professional service, if a diagnosis present during the hospitalization is resolved on the day of discharge and the documentation reflects this, do you code the resolved condition or code only active conditions on the date of discharge?
SuperCoder Answered Mon 31st of July, 2017 06:29:47 AM

Hi,

As per coding guidelines, If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy.

Thanks

Please find the below link:

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-ICD-10-CM-Guidelines.pdf

Kerri Posted Thu 10th of August, 2017 11:52:53 AM
Does section III page 99 from the CMS link you referenced, does this pertain to Professional Fee charges as well as facility IP/OP charges.
SuperCoder Answered Fri 11th of August, 2017 08:01:53 AM

Yes, this pertain to Professional Fee charges as well as facility IP/OP charges.

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