Wiki Coding guidelines for outpatient ER

[bwilliams31]

I have a question regarding outpatient coding guidelines. Example ER doctor patient comes in with abcess and they do a I&D patient is discharged the discharge dx is abcess of abdominal wall. The wound culture comes back stating the patient has Staphylococcus Aureus has been identified as MRSA. I am under the understanding that we as coders can code from a radiology report and a Pathology report only. We can't code from labs without the doctor stating that in his documentation.

thanks for you help in advance!

 

[LTibbetts]

I have come across a lot of these situations myself being an ER coder and it is frustrating to not be able to code a lab result after the fact, but as far as my interpretation of the coding guidelines, you can not code it unless the physician has confirmed it at the time you are coding the chart. Under section IV in the guidelines, under L., it states:

"For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation."

which would leave me to believe that if it isn't confirmed at the time of coding, then you can not use it. I, myself, do count the labs under this type of guideline as well as the xrays, EKG's. Other interpretations may vary, but this is how I do it

 

[mitchellde]

A coder may code a dx rendered by a physician. Xrays that have a radiologist interpretation the coder may code as he is a physician. Same with pathology. Lab however has not had a physician interpretation, it is a result without interpretation therefore we must wait until the physician provides this.

 

[karriaga]

Hiv/aids coding in the ER

We have different opinions in my office for coding HIV or aids for ER patients. Some think that in the guidelines "admission" means inpatient. We code only ERs. Does "admission" = encounter(i.e. an ER patient)?