ED Coding and Reimbursement Alert

Question: A patient reports to the ED complaining of pain in his arm, lower back and chest. The ED physician admits the patient to observation status at 8 a.m. Tuesday, where he orders blood tests to check enzyme levels and an electrocardiogram (EKG), which is interpreted by a cardiologist. Following serial examinations, all of the patient's lab work comes back normal. During the course of the blood testing, the patient informs the physician that he had been bench pressing free weights the night before, and he "might have" strained himself. The ED physician discharges the patient at 6 p.m. Tuesday, with a diagnosis of pain caused by heavy lifting. Notes indicate a detailed comprehensive history and examination. Should I include the three ICD-9 codes for the patient's pain as well as an E code? Or just the E code?

Minnesota Subscriber

Answer: You should include four ICD-9 codes on this claim, both for compliance reasons and to ensure better patient care. On the claim, report the following:

• 99235 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity ...) for the observation service
• 786.59 (Symptoms involving respiratory system and other chest symptoms; chest pain; other) appended to 99235 to represent the patient's chest pain
• 724.2 (Lumbago; low back pain) appended to 99235 to represent the patient's back pain
• 729.5 (Other disorders of soft tissues; pain in limb) appended to 99235 to represent the patient's arm pain
• E010 (Activity involving other muscle strengthening exercises; push-ups, pull-ups, sit-ups) appended to 99235 to represent the cause of the patient's injuries.

Why so many Dxs? Submitting an E code as the primary diagnosis is incorrect coding. E codes are designed to be secondary diagnoses that supplement the primary ICD-9 code[s].

Also, thorough diagnosis coding leads to better patient outcomes. The main purpose of ICD-9 coding is to paint a clear picture of the patient's condition. When another provider looks at this patient's chart, she'll know exactly what type of pain the patient suffered -- and how he suffered the injury.