Amaurosis fugax
Just had our coder ask me what I thought was an easy question, but I find I am struggling with it:
Patient was diagnosed w/amaurosis fugax d/t CAS back in January. She hasn't had any symptoms since, but she came here for a CEA. The admitting diagnosis in the H/P and consults is amaurosis fugax and CAS, so it is documented by our physicians.
The question from our coder is whether we can take amaurosis fugax as a current diagnosis/CC, given that she has been asymptomatic since before her admission, and if so, is it considered present on admission?
I thought right off the bat that it was ok because it's documented, but upon further review, I'm not so sure. Coding clinic isn't much help.
Thanks in advance for the collective brain trust,
Renee
Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital
Patient was diagnosed w/amaurosis fugax d/t CAS back in January. She hasn't had any symptoms since, but she came here for a CEA. The admitting diagnosis in the H/P and consults is amaurosis fugax and CAS, so it is documented by our physicians.
The question from our coder is whether we can take amaurosis fugax as a current diagnosis/CC, given that she has been asymptomatic since before her admission, and if so, is it considered present on admission?
I thought right off the bat that it was ok because it's documented, but upon further review, I'm not so sure. Coding clinic isn't much help.
Thanks in advance for the collective brain trust,
Renee
Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital
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