ED Coding and Reimbursement Alert

Question: A parent brought a newborn patient to the ED with nasal discharge, nasal swelling, and fever. The physician documented a concern for sinus infection. Do I have to ask the physician for more information before I can code this scenario?

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Answer: Despite the lack of a definitive diagnosis explaining the newborn's symptoms, this diagnosis can be coded as is, without further elaboration by the provider. If, for example, there were a test that the provider could perform to definitively diagnose a sinus infection, then you could send the report back in case the provider performs the test after he or she documents these indicating diagnoses.

An example where this scenario may apply is if the newborn had symptoms that prompted the provider to consider the possibility of allergies. Assuming the physician performs an allergy test on the newborn, you could send the chart back to the provider for an update as to whether allergies are actually the culprit of the newborn's symptoms.

In this example, you will simply code the three underlying symptoms. Due to a lack of a more specific diagnosis for nasal discharge and nasal swelling, you will apply the same P code for both diagnoses: P28.89 (Other specified respiratoryconditions of newborn). As for the fever, you will apply code P81.9 (Disturbance of temperature regulation of newborn, unspecified).