ED Coding and Reimbursement Alert

Nowhere is the debate over billing for signs and symptoms more apparent than in the ED where "coders have to realize that while a physician coder and a hospital coder technically belong to the same profession, the two types of coding are completely different," says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City.

Physician coders are typically taught to code signs and symptoms first. The Federal Register (March 4, 1994, Section 42 CFR Part 424) has enjoined coders to "list first the code for the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided." They interpret the "reason for the encounter/visit" to mean the reason the patient showed up in the ED.

On the other side of the debate, coders who were trained in hospital coding or medical records departments look only at the final diagnoses. They take the ICD-9 directive to code to the highest level of specificity to mean the most specific diagnosis in the chart. They interpret the "reason for the visit" to point to the underlying cause of the patient's signs and symptoms. Indigestion is not a heart attack, and that's that, the reasoning goes.

The reality of the ED is that when, for example, a patient presents with chest pains, everything stops: The patient gets put on a cardiac monitor; he may get a chest x-ray and undergo several tests. Not until the physician has determined that it's not a cardiac event can he or she explore less serious alternatives, such as gastritis (535.0x) or costochondritis (733.6).

So, who's right? According to Thomas, both parties are correct in their separate spheres. The main goal of emergency physician coding, however, is "to paint a clear picture of the ER encounter and include for the payer a clear idea of what the emergency physician had to go through to treat this patient." Francis D. Hilario, BSN, RN, CPC, coding quality manager at the Hospital of the University of Pennsylvania, also tells new ED coders to "make a story out of the patient's complaint."

The patient with the apparent cardiac emergency may walk away with a final diagnosis of gastritis, but the physician and staff still performed the work associated with gathering an EKG, chest x-ray and cardiac enzymes. Thomas says it's right and appropriate to code the reason for the visit as 786.50 (Chest pain, unspecified) and the diagnosis as 535.50 (Unspecified gastritis and gastroduodenitis).