If the pre and postoperative diagnosis are different, the preoperative diagnosis should be coded.
According to the ICD-9-CM guidlelines, when coding anemia associated with a malignancy, the following statement is true:
Malignancy followed by anemia.
In the outpatient setting a diagnosis that is documented as "rule out" should be coded as if it exists.
Established patient seen for redness and discharge from the right eye. A diagnosis of bacterial conjunctivitis was made.
If a patient is admitted for observation for a medical condition, a code is assigned for the medical condition as the first-listed diagnosis.
Trina is admitted for chemotherapy treatment after a mastectomy.
Mastectomy, then encounter for chemotherapy.
Initial office visit for patient with diarrhea. Physician documented gastroenteritis.
In the outpatient setting the term first-listed diagnosis is used instead of principal diagnosis.
Regina was admitted for treatment of her breast cancer. Immediately after her mastectomy, she was taked to chemotherapy.
Breast cancer, then encounter for chemotherapy.
Which is the first-listed diagnosis? Established patient presents with chest pain. Has a history of previous myocardial infarction.
It is acceptable to use codes that describe signs and symptoms when a definitive diagnosis has not been established by the provider.