ED Coding and Reimbursement Alert

Question: A 73-year-old female presents to the ED because she is very weak. She had an irregular pulse the week before and was placed on Lanoxin. The ED physician orders an EKG, cardiac labs and chest x-ray. After the exam and review of the tests, the doctor's diagnosis is "weakness with workup." Also noted in the past medical history are diabetes mellitus (DM), chronic heart failure (CHF) and hypertension (HTN). Would it be correct to code the weakness first and also include the DM, CHF and HTN as secondary diagnoses?

Minnesota Subscriber
 
Answer: Although it is not recommended to code diagnoses strictly from the patient's past history, it is sometimes necessary to do so. It would be appropriate to code the weakness as the primary diagnosis and also the DM, CHF and HTN because they are coexisting diagnoses and relate to the current patient status.
 
It appears the ED physician ordered a cardiac workup because of the presence of CHF and HTN. The history of diabetes dictated at least some of the labs, while hyperglycemia was probably ruled out based on the results. Diabetes-related complications may be ruled out with the lab tests ordered as well. The following diagnosis codes may apply: 
 
780.79 other malaise and fatigue (asthenia NOS, lethargy, postviral [asthenic] syndrome, tiredness)
 
402.91 hypertensive heart disease; unspecified; with congestive heart failure
 
250.0x diabetes mellitus without mention of complication [needs a fifth digit to specify type].
 
 
The E/M level should be appropriately supported by the physician documentation of the history of present illness (HPI), exam and medical decision-making (MDM). Based on this scenario, it would likely be 99284 (emergency department visit for the evaluation and management of a patient, which requires a detailed history and examination, and medical decision making of moderate complexity). Report 93010 (cardiography, interpretation and report only) for the professional component of the EKG interpretation, and 71010 (radiologic examination, chest; single view, frontal) or 71020 ( two views, frontal and lateral) with modifier -26 (professional component) attached to indicate the interpretation or professional component. In most instances, the lab codes would be billed on the facility side.
 
Remember to append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service code when procedures are also performed and reported.
 
The primary diagnosis listed should correlate to the main reason for the procedure, service or supply provided. Any additional codes that describe coexisting or underlying conditions should be listed second. CMS states that diagnoses documented as "probable," "suspected," "questionable," or "rule out" should not be coded as if the diagnosis is confirmed. The symptoms, signs, abnormal tests or other reasons for the encounter should be coded to the highest [...]