ED Coding and Reimbursement Alert

Question: A patient reports to the ED complaining of severe stomach pain and trouble urinating; he says it's been "almost two days" since he could urinate without "9 out of 10" pain. The ED physician orders a urinalysis, finds blood in the urine, and refers the patient to a urologist for further care. What ICD-9 codes should I use to report this scenario?South Carolina SubscriberAnswer: The physician diagnosed the patient with hematuria, but you'll have to do some more digging to arrive at the most accurate diagnosis code. On the claim, report the appropriate-level ED E/M code based on the encounter notes (99281-99285, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: ...).Dx coding: Double-check with the physician or check the notes to see if the blood was visible to the naked eye, or if the physician needed visualization to spot the [...]