Question

A patient has an inpatient discharge with principal diagnosis of shoulder pain due to peptic ulcer vs. cholecystitis documented on the history and physical. Both are equally treated and well documented. A coder should:

-Code whichever diagnosis pays more, if both are equally treated
-Use a code from the Findings Abnormal category
-Code to the most severe symptom
-Code shoulder pain, peptic ulcer, cholecystitis

Answer 1

A medical coder should code both peptic ulcer and cholecystitis, along with shoulder pain, following clinical accuracy and specificity in documenting the patient's conditions treated during the inpatient stay.

Step-by-step explanation:

Appropriate Coding for a Patient's Principal Diagnosis

When a patient is discharged with multiple diagnoses that have been equally treated and well documented, such as shoulder pain due to peptic ulcer versus cholecystitis, the correct course of action for a medical coder is not to code whichever diagnosis pays more. Instead, the coder should adhere to coding guidelines which prioritize clinical accuracy and specificity. Both peptic ulcers and cholecystitis should be coded, along with shoulder pain, as these are the conditions identified and treated during the inpatient stay.

Peptic ulcers and cholecystitis are documented using specific ICD codes to accurately reflect the patient's condition and the medical services provided. These codes are integral to the healthcare management system, guiding treatments, and processing claims for insurance reimbursement. Clinicians, laboratories, and healthcare providers rely on accurate coding for effective communication and service delivery.