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Q&A: Selecting principal diagnosis when physician uses "versus"
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests, but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).”
When I first started as a CDI specialist I was told we could not use diagnoses when "versus” was stated, and that we had to query for clarification.
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