ED Coding and Reimbursement Alert

Question: Our ED physician recently saw a pediatric patient with a very high fever and suspected that the young girl had sepsis. Should we report the diagnosis code for sepsis or for the signs and symptoms she exhibited?

New York Subscriber

Answer: Correct diagnosis coding in this instance depends on the documentation in the patient record. If the ED physician stated that the diagnosis was sepsis, report the relevant code (e.g., 038.8, Septicemia; other specified septicemias). However, if the physician's notes stated he or she was attempting to "rule out" sepsis, the signs and symptoms should be coded (e.g., 780.6, General symptoms; fever).
 
When reviewing documentation, emergency department coders may see physician notes indicating that tests are being done to rule out or confirm a probable diagnosis. These terms and similar language such as "suspected" and "questionable" do not support the medical necessity of outpatient services (although they are acceptable when billing for hospital inpatients). CMS guidelines for reporting outpatient services, in fact, explicitly state that practices should not use the condition being ruled out as the diagnoses. Instead they should "code the condition(s) to the highest degree of certainty for that encounter/visit such as symptoms, signs, abnormal test results "
 
"Rule out" and related terms often cause improper coding. Coders need to look a bit further and find out why the study was done. Something prompted the ED physician to suspect the disease in the first place. Coders should assign the appropriate codes describing those signs and symptoms.
 
For instance, if a chest x-ray (i.e., 71020, Radiologic examination, chest, two views, frontal and lateral) was done to rule out tuberculosis (TB) in an individual who had been in contact with a TB patient, the coder may assign 786.2 (Cough) if documented and V01.1 (Contact with or exposure to communicable diseases, tubercu-losis) to describe the symptoms. However, the coder should not report a code from the 011.x series (Pulmonary tuberculosis).