Resolved Hemiparesis as PDX (G81.94)

[StacieH_45586]

In the inpatient setting, patient was principally tx for CVA, however, after study (4 CT's, 1 MRI) every one of them were unremarkable for a cerebral infarction. He was tx with Tenteplase, but again, after study the patient was negative for stroke. The patient also had documented left sided hemiparesis. Can this be coded as the primary? Other dx ruled out were Bell's Palsy. All I have left it seems is weakness (R-cde) and Hemi-(G81.94)

 

[Darcy]

In the inpatient setting, patient was principally tx for CVA, however, after study (4 CT's, 1 MRI) every one of them were unremarkable for a cerebral infarction. He was tx with Tenteplase, but again, after study the patient was negative for stroke. The patient also had documented left sided hemiparesis. Can this be coded as the primary? Other dx ruled out were Bell's Palsy. All I have left it seems is weakness (R-cde) and Hemi-(G81.94)

Section II. Selection of Principal Diagnosis
The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
H. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

*These guidelines are for inpatient hospital coders - coding for the hospital
Your scenario did not specify if you were coding for the physician or the hospital