ED Coding and Reimbursement Alert

Hint: Diagnosis codes alone won’t support medical necessity.

Your emergency department doesn’t just see patients with accidents and illnesses, but also those with chronic conditions who are looking for answers that might explain their symptoms. Evaluating how to report the diagnosis codes for these conditions can be challenging, but if you take the appropriate steps, you’re on your way to success.

Check out the following three cases and determine what you would do to solve the coding puzzle. Then check out the solution to determine whether you came up with the right diagnosis code.

Case 1: Neck Sprain

Scenario 1: The ED provider treats a patient complaining of neck pain that’s been getting worse ever since the patient fell out of bed three weeks ago. She says she initially thought it would resolve on its own, but now she’s worried that maybe there’s a spinal fracture. After an examination and an X-ray, the ED physician determines that the patient is suffering from a neck sprain.

Coding Solution: You may have to get a little bit more information to select the most accurate code. First, you’ll need to find out which ligaments or joints were sprained in the neck.

Your options include:

• S13.4xx- (Sprain of ligaments of cervical spine)
• S13.8xx- (Sprain of joints and ligaments of other parts of neck)
• S13.9xx- (Sprain of joints and ligaments of unspecified parts of neck)

Note: Each of these codes requires a seventh character to note encounter status: A (Initial encounter), D (Subsequent encounter), or S (Sequela).

So, if the notes indicate that a patient presents with neck pain for the first time (which is the likeliest situation in the ED and based on the description of the encounter), and the provider diagnoses a sprain of the cervical spine ligaments, you’d report S13.4xxA for the encounter. You should also add a code from Chapter 20 to describe how the neck sprain happened if known (i.e., W06.xxxA, Fall from bed, initial encounter).

Case 2: Portal Hypertension

Scenario 2: Your ED physician sees a 64-year-old male patient for complaints of abdominal pain, vomiting, and nausea that have been persistent for the past two weeks. The patient also complains of severe weight loss for a couple of months now. The patient is HIV positive and has been on antiretroviral therapy for about four years. He has no history of alcohol intake or drugs. He says that he has had no abdominal complications until now.

Upon examination, your clinician notes signs of anemia, dyspnea, tachypnea, and ascites. Your ED physician orders lab tests including CBC, coagulation time, LFT, BUN, creatinine, albumin, globulin and bilirubin levels. The LFTs how increased levels of AST (Aspartate transaminase); ALT (Alanine transaminase) and GGT (Gamma Glutamyl Transpeptidase) while creatinine, albumin, globulin, and bilirubin levels are all normal.

The patient’s abdominal CT scan shows the presence of ascites and portal vein thrombosis. There are no signs of any splenomegaly. Based on history, signs and symptoms, physical examination, and results of lab tests and diagnostic studies, your clinician arrives at a diagnosis of portal hypertension.

Coding Solution: You should report the diagnosis with K76.6 (Portal hypertension).

Reminder: Although in this case alcohol was not the cause of portal hypertension, in cases where alcohol is involved, you’ll have to also use an additional code to help identify alcohol abuse and dependence (F10.-). The choice of which code to select will depend on whether the alcohol use disorder is still active or in remission, advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a physician and former CPT^® Editorial Panel member in Pasadena, California.

Case 3: Absence of Symptoms

Scenario 3: A mother brings her 4-year-old to your ED, saying the child has been acting like he is ill, but she can find nothing wrong. Your ED physician examines the child, speaks to him about his complaints, and orders a glucose level by fingerstick, as well as a urinalysis. Ultimately, the ED provider agrees with the mother; the physician records no diagnosis, signs, or symptoms.

Coding Solution: For so-called “worried well” or “feared well” scenarios, where a patient does not receive a diagnosis, or the provider records no signs or symptoms in the medical record, you can use either Z03.89 (Encounter for observation for other suspected diseases and conditions ruled out) or Z71.1 (Person with feared health complaint in whom no diagnosis is made). And even though “worried well” is a synonym for Z71.1, there are important, subtle differences between the codes that you should bear in mind before assigning one or the other.

The Z03 codes are to be used “when a person without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, which requires study — but after examination and observation, is ruled out,” according to ICD-10. This means the code is more appropriate for situations when there is reason to suspect the child may have a condition, but the provider needs to wait to make a definitive determination on the patient’s condition.

The Z71 codes, however, are used for “persons encountering health services for other counseling and medical advice, not elsewhere classified,” also according to ICD-10 guidelines. This means your use of Z71.1 implies that the care was more to reassure the parent and reduce caregiver anxiety.

Be careful: Most, if not all, payers will not reimburse for Z71.1. The best code to use in this situation is Z03.89, as a pediatric patient will present with something the parent believes could be a problem, but the ED physician will make the determination that the patient does not have any issues after doing a history and exam.

Remember: Go Beyond the Diagnosis

Once you have the diagnosis code nailed down, remember that you must also have documentation that supports medical necessity of the services your ED provider performs. Some coders will see a specific ICD-10-CM code listed on a local coverage determination (LCD) and assume that as long as their patient’s diagnosis code matches that, then the claim will sail through the approval process — but that isn’t accurate, said Kathy Boehm, senior provider relations representative with Palmetto GBA, during the Part B payer’s May 20 webinar, “Part B: Medicare Follows the Money.”

“A diagnosis code by itself on a claim does not alone support medical necessity, and documentation for each patient’s encounter must be maintained to support medical necessity,” she noted. “Medical necessity of a service is the overarching criterion for payments in addition to the individual requirements of the CPT^® or HCPCS code that’s being billed.”