PDX Selection in AMA Discharge Cases – Dysphagia & Esophageal Candidiasis

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Can You Code Oral or Esophageal Candidiasis as Principal Diagnosis in an AMA Discharge?

Case Scenario

A patient is admitted with dysphagia and generalized weakness, and there is a clinical concern for esophageal candidiasis. However, the patient left Against Medical Advice (AMA) before a complete workup or treatment could be done.

 In the last day’s progress notes, the provider documents a concern for oral and esophageal candidiasis.

Key Coding Question: Can we assign oral and/or esophageal candidiasis as the principal diagnosis (PDX) in this case?

Coding Guidance

Principal Diagnosis Determination

so here’s the official definition straight from ICD-10-CM land

the principal diagnosis is the condition established after study that was mainly responsible for getting the patient admitted.

but when a patient bails AMA style, you gotta work with whatever was documented before they bounced. usually the last progress notes are your best bet.

In this case

  • patient came in because they had dysphagia and weakness
  • last note said the doc was concerned about oral and esophageal candidiasis
  • nobody confirmed anything else for sure

So, what’s the answer?

yep, you can assign oral and or esophageal candidiasis as the principal diagnosis here. based on the symptoms and the notes, it makes sense that was the reason for admission.

no need to overthink it.

Code Options

  • B37.0 — Candidal stomatitis aka oral thrush
  • B37.81 — Candidal esophagitis

if the notes talk about both, you can use both codes. easy money.

Coding Tip

 always doublecheck that the notes back up the dx you are coding.

AMA discharges are weird because you do not have the full picture but you still have to code based on the best guess at the time, using clinical judgment.

one thing tho — be careful coding "concern for" stuff unless the doc actually treated it like it was real or the notes give strong clues.

Conclusion

in this case, since the provider specifically mentioned oral and esophageal candidiasis right there in the final note, and nothing else was officially diagnosed, you are good to go coding it as principal dx.

either one or both depending what the notes say.

just make sure the documentation backs you up. and if it is feeling sketchy, just shoot a quick query to the provider. better safe than sorry.

 


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