ED Coding and Reimbursement Alert

Find out what the experts say about what takes precedence

After reading our article "Win the Battle: Diagnoses Versus Signs and Symptoms" in the March 2004 issue of ED Coding Alert, many readers wrote in wanting hard documents to back up our statements. You request, we deliver: Take these sources to carriers who deny claims with signs and symptoms to back up your claims - they all specifically state that you can indeed report signs and symptoms in certain cases in the ED.

Up to Bat: The Federal Register

 If your carrier takes issue with your claim because you reported signs and symptoms, show them the March 4, 1994, issue of the Federal Register. Section 42, CFR part 424 specifically states that while reporting symptoms isn't OK for inpatient claims, "codes for symptoms and signs are appropriate and acceptable for physician reporting."
 
Look closely, because that section repeatedly states that what your codes explain to the carrier is why the patient needed emergency care - and sometimes, that reason isn't a definitive diagnosis.
 
For example, the Federal Register's instructions tell you, "List first the code for the diagnosis, condition, problem, or other reason for the encounter shown in the medical record to be chiefly responsible for the services provided." If you're showing the Federal Register to your carrier to back up your claim, save time by underlining the part of these instructions after "or," because that's the part that justifies a chest x-ray when a patient's final diagnosis was esophageal reflux.

Take a Swing at Denials: Medicare Carriers Manual

Section CAR 4020 of the MCM, titled "Review of the Health Insurance Claim Form," supports the Federal Register's instructions, stating the following: "Code the condition to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit."

Bring Payment Home: Coding Clinic

According to the American Hospital Association's Coding Clinic, a patient who presents to the ED complaining of severe chest pain leaves the ED with a diagnosis of gastritis. For the "reason for visit," Coding Clinic instructs you to report 786.50 (Chest pain, unspecified) - a symptom - and 535.5x (Unspecified gastritis and gastroduodenitis) for the "diagnosis."