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I am an emergency room coder, and would like to get some input as to what you all think, as I continually go back and forth in regards to second guessing myself on these issues.
Here's the scenario:
A patient chief complaint is Suicidal and Homicidal thoughts...and in the review of symptoms, physician states, patient has had depression. The final dx at times will only list Bipolar.
My questions are:
1. Would you pick up the SI and HI as the Dr. acknowledges the patient has in fact had these thoughts...though fails to put it as a final dx (and these aren't symptom codes)
2. Physician acknowledges patient had been depressed within the report, but doesn't put Bipolar, with Depression as a final dx. Would you code, (combined) Bipolar currently depressed; Bipolar, secondary dx depression, or leave the depression out completely?
3. Am I totally overthinking this or what?!?!?!!?
Another scenario...is where a patient comes in and all over the place, the chart will say things like USES heroine, smokes marijuana....no matter how its worded, statement usually falls short of the coveted "substance ABUSE". so although I KNOW anyone that shoots heroine is abusing it by nature, since the Dr only says drug use, I don't pick up the abuse code. Am i doing this right?
Here's the scenario:
A patient chief complaint is Suicidal and Homicidal thoughts...and in the review of symptoms, physician states, patient has had depression. The final dx at times will only list Bipolar.
My questions are:
1. Would you pick up the SI and HI as the Dr. acknowledges the patient has in fact had these thoughts...though fails to put it as a final dx (and these aren't symptom codes)
2. Physician acknowledges patient had been depressed within the report, but doesn't put Bipolar, with Depression as a final dx. Would you code, (combined) Bipolar currently depressed; Bipolar, secondary dx depression, or leave the depression out completely?
3. Am I totally overthinking this or what?!?!?!!?
Another scenario...is where a patient comes in and all over the place, the chart will say things like USES heroine, smokes marijuana....no matter how its worded, statement usually falls short of the coveted "substance ABUSE". so although I KNOW anyone that shoots heroine is abusing it by nature, since the Dr only says drug use, I don't pick up the abuse code. Am i doing this right?
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