It’s my understanding inpatient physician practice coding is no different than physician office coding . . . you code definitive diagnoses only and if you don’t have a definitive diagnosis, you code signs and symptoms. However, I have also been told it’s okay to code a definitive diagnosis if the physician states (for example): "The patient’s CT scan was consistent with an anoxic brain injury" or "The patient likely has an anoxic brain injury based on their CT scan".
If this was the only information you were given to base your coding off of, would you code an anoxic brain injury or would you code abnormal head CT findings?
I like for things to make sense to me. I have an extensive background in various medical fields, but I find myself trying to find where to drawn the line on what’s definitive and what’s not. Thanks in advance!