I have always coded both - for example - CVA vs. TIA. If it is not determined which caused the admission and that is the final word from the physician, we were always told to code both. And because CVA was POA and has a higher weight it may be used as PDx w/TIA as CC. This was the advice we had from our Coding Consultant several years ago.
In the example of "Chest Pain - Costochodritis vs. GERD" - there is a Coding rule of a Symptom used as PDx with contrasting diagnoses listed as SDx.
In other words, it was never decided by the physician which caused the Chest pain - it could have been either or both. So you would list the Chest Pain as PDx followed by the two other diagnoses.
N. Brunson, RHIA Clinical Documentation Specialist Bay Medical Center
Comments
My interpretation of the versus used in coding a condition is "or".
determined which caused the admission and that is the final word from
the physician, we were always told to code both. And because CVA was
POA and has a higher weight it may be used as PDx w/TIA as CC. This was
the advice we had from our Coding Consultant several years ago.
In the example of "Chest Pain - Costochodritis vs. GERD" - there is a
Coding rule of a Symptom used as PDx with contrasting diagnoses listed
as SDx.
In other words, it was never decided by the physician which caused the
Chest pain - it could have been either or both. So you would list the
Chest Pain as PDx followed by the two other diagnoses.
N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center