Meredith Posted Mon 04th of January, 2016 11:30:37 AM
Pt came in for swingbed secondary to fractured right hip with femoral head with closed head injury. Is there a general rule about coding a rehab DX as first listed diagnosis or should i just code the daignoses listed in note?
SuperCoder Answered Tue 05th of January, 2016 03:55:13 AM
You should code diagnosis listed in the note as first listed diagnosis. Please find below ICD-10-CM guidelines for rehab DX-
When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed. For example, for an admission/encounter for rehabilitation for right-sided dominant hemiplegia following a cerebrovascular infarction, report code I69.351, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, as the first-listed or principal diagnosis. If the condition for which the rehabilitation service is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis. For example, if a patient with severe degenerative osteoarthritis of the hip, underwent hip replacement and the current encounter/admission is for rehabilitation, report code Z47.1, Aftercare following joint replacement surgery, as the first-listed or principal diagnosis.