New to inpatient, I know inpatient is allowed to code for ” rule out ” or ” suspected” .. but getting a bit confused. I have a H&P, provider is admitting the patient. Do
Patient came from ER for CHEST PAIN and no assessments have been done yet to determine exact dx.
H&P Provider documented:
# TIA VS SYNCOPAL EPISDOE MUST RULE OUT (CARDIAC ETIOLOGY RECENT + LEXISCAN)
#AKI LIKELY PRE RENAL (GFR 58 AND CR 1.07 ON 6/22/18)
#NON-AGMA (BICARB16)
#HTN
# LACTIC ACIDOSIS
Do i code the rule out dx as well as chest pain? or just chest pain and everything else provider documented. HELP!
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