# ER physician problem



## gsbrown (Sep 19, 2008)

I'm having a problem with a few of my ER doctors wanting to use "fall without injury" as a primary diagnosis.  We have tried to explain to them that this is not a diagnosis, but rather the act or cause of an injury.  We have tried to explain to them that we could use a "worried-well" code or other "V" code for observation after accident.  They just don't seem to get it when we try to explain this to them, and continue to write "fall" as their diagnosis.  Does anyone have any suggestions on how to handle this?  Thanks.


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## FTessaBartels (Sep 19, 2008)

*Feared Complaint, Not Found*

Are they filling out a charge sheet, or are you coding from documentation? In either case, keep plugging away at trying to educate the docs on codable diagnosis (ICD-10 will be even MORE specific). 

I'd probably use V65.5 Person w/ feared complaint in whom no diagnosis was made  -*and*-  E888.9 (or other E code if I knew specifics of fall).

F Tessa Bartels, CPC, CPC-E/M


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## okiesawyers (Sep 19, 2008)

*E Codes*

I would take my ICD-9 book to the doctors and show them on page 23, #19 of the coding guidelines where it states "E codes are to never be recorded as principal diagnoses". Let the conversation go from there and you can then guide them to the correct primary diagnosis.


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## msbrowning (Sep 19, 2008)

Can E Codes be used as an admitting diagnosis? For example, patient presents to the ER due to motorcycle accident (E code) complaining of back and neck pain. Would the back and neck pain be the admitiing diagnosis? Or would the MVA be the admitting diagnosis or would both be the admitting diagnosis? Is it possible/allowable to have more than one admitting diagnosis in the ER?


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## okiesawyers (Sep 19, 2008)

msbrowning said:


> Can E Codes be used as an admitting diagnosis? For example, patient presents to the ER due to motorcycle accident (E code) complaining of back and neck pain. Would the back and neck pain be the admitiing diagnosis? Or would the MVA be the admitting diagnosis or would both be the admitting diagnosis? Is it possible/allowable to have more than one admitting diagnosis in the ER?



Your injury codes, neck and back pain would be listed first, then the E codes would be added to identify the nature and the place of the accident.  Please look at your ICD-9 guidelines as I stated above, it paints a clear picture of using E codes.


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## msbrowning (Sep 21, 2008)

When coding IVP's for the ER, is it necessary to use the HCPCS book to identify the drug that was given, for example patient was given an IVP with Zofran at 10:30 pm? I did code the IVP as 90774. Also, if the patient was given Zofran at 10:30 pm and then again at 2:30 am, do I code it as 90774 x 2 or would I code it as 90774, 90775 or would I code it as 90774, 90776? 

At first I thought 90774, 90775 but 90775 states each additional seqeuntial intravenous push of a new substance/drug, but since it is the same drug, Zofran, I am unsure if this is the correct code. 

Now 90776 states each additonal sequential intravenous push of the same substance/drug provided in a facility (List seperately in addition to code for primary procedure), so being that the Zofran is the same drug that I coded in 90774, would I code the additional push as 90776? Now if the patient was given the IVP with Zofran at 3 different times, how would I code it, 90774, 90776 x 2?

Also, how would I code an IV that was started in the field and monitored in the ER, if I code it at all. For example, patient arrived at the ER via helicopter at 815 am (motorcycle accident) IV was started in the field, pt was given an IVP of Zofran at 10:15 am and another one at 2:15 pm. Before patient was discharged IV was noted to still be running. Do I code the IV and the IVP or just the IVP?

Thanks in advance


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## jccoder (Sep 21, 2008)

msbrowning said:


> When coding IVP's for the ER, is it necessary to use the HCPCS book to identify the drug that was given, for example patient was given an IVP with Zofran at 10:30 pm? I did code the IVP as 90774. Also, if the patient was given Zofran at 10:30 pm and then again at 2:30 am, do I code it as 90774 x 2 or would I code it as 90774, 90775 or would I code it as 90774, 90776?
> 
> At first I thought 90774, 90775 but 90775 states each additional seqeuntial intravenous push of a new substance/drug, but since it is the same drug, Zofran, I am unsure if this is the correct code.
> 
> ...


For the first question, we do not charge for the drug, the pharmacy does that.  You would code 90774 and 90776 for Zofran for 10:30 and 2:30.  If Zofran is given at 3 different times as long as there is at least 30 minutes between pushes, you would code 90774 90776x2.  
Only code what is done in your ED dept.  If a drug is infusing when you receive a patient, you can start the clock when the patient is admitted to your ED.  If Zofran was given at 10:15 in the field and you gave it at 2:15, then I would only code 90774 for the 2:15 push.
_That is my opinion on this question._


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## msbrowning (Sep 21, 2008)

Ok, so if the IV was started in the field and the ER administered the IVP (meds through the IV that was started in the field), I only code the IVP? So, can I just eliminate the fact that the IV was started in the field because my ER physician or nurse did not start it?

Also, if a patient receives two different procedures in the Er, for example an IVP and a CT, do I need to use a modfier?

Is there a certain modifier that is always used in the ER regardless of the procedure or procedures that are billed? I guess what I am asking is, is there one modifier that should be attached to every procedure that I code in the ER?


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## msbrowning (Sep 21, 2008)

okiesawyers said:


> Your injury codes, neck and back pain would be listed first, then the E codes would be added to identify the nature and the place of the accident.  Please look at your ICD-9 guidelines as I stated above, it paints a clear picture of using E codes.



Hi Amy,
Thanks for responding, I would like to ask you a question since you are an auditor. How do I choose the E/M level in the ER. For example if a pregnant patients present to the ER with vaginal bleeding, would i could that as a 99284 or a 99285? What about a burn patient with 25% or 30 % third degree burns?


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## okiesawyers (Sep 22, 2008)

msbrowning said:


> Hi Amy,
> Thanks for responding, I would like to ask you a question since you are an auditor. How do I choose the E/M level in the ER. For example if a pregnant patients present to the ER with vaginal bleeding, would i could that as a 99284 or a 99285? What about a burn patient with 25% or 30 % third degree burns?



Hi Ms Browning,
It's still going to all depend on your documentation.  I still use my audit tool to circle all the information from the note, then I look in the CPT book for the definitions of the ER codes, note that all ER codes must meet 3 out of the 3 in order to qualify for the highest level.  In the MDM you could almost always use a 3 or 4 in Box A due to it more than likely being a new problem.  The problem that I have found with doctors in the ER is not enough documented examination, which will bring down your overall E&M since 3 out of the 3 must be met. Let me know if you need anything else.  I am also going to PM you!
Good luck,
Amy


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## msbrowning (Sep 22, 2008)

Thank you. I replied to your PM.



okiesawyers said:


> Hi Ms Browning,
> It's still going to all depend on your documentation.  I still use my audit tool to circle all the information from the note, then I look in the CPT book for the definitions of the ER codes, note that all ER codes must meet 3 out of the 3 in order to qualify for the highest level.  In the MDM you could almost always use a 3 or 4 in Box A due to it more than likely being a new problem.  The problem that I have found with doctors in the ER is not enough documented examination, which will bring down your overall E&M since 3 out of the 3 must be met. Let me know if you need anything else.  I am also going to PM you!
> Good luck,
> Amy


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## jccoder (Oct 5, 2008)

msbrowning said:


> Ok, so if the IV was started in the field and the ER administered the IVP (meds through the IV that was started in the field), I only code the IVP? So, can I just eliminate the fact that the IV was started in the field because my ER physician or nurse did not start it?
> 
> Also, if a patient receives two different procedures in the Er, for example an IVP and a CT, do I need to use a modfier?
> 
> Is there a certain modifier that is always used in the ER regardless of the procedure or procedures that are billed? I guess what I am asking is, is there one modifier that should be attached to every procedure that I code in the ER?



Yes, charge the IVP since the drug was administered in the ED.  When the patient receives an IVP and a CT then you would add a modifier 59 to the IVP if the CT was done with contrast.  The most commonly used modifier in the ED is the 25 that is added to the E/M code when something separately identifiable is coded.
_That is my opinion on these questions._


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## JEMiller (Oct 5, 2008)

What about V71.4, observation following accident...? Just a thought.


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