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Inpatient Admission Diagnosis


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!