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Hello,
I am a coder/biller for an ER and have to read the patients file and code from there. My question is for example, when I have a patient that came in to the ER with symptoms such as abd pain, abd tenderness, vomiting, diarrhea and fever and the doc determined he had Gastroenteritis do I code the gastroenteritis only or do I use it as my principle dx and still code all the symptoms that follow? I have heard that, since all those symptoms are integral to the dx-gastroenteritis you don't code the symptoms but what about fever? that can be a symptom and sometimes it's not, so should I code that one too? Also, if I do code the symptoms is this a fraud?? Can I loose my certificate or raise a red flag for an audit on my practice?
Thank You
I am a coder/biller for an ER and have to read the patients file and code from there. My question is for example, when I have a patient that came in to the ER with symptoms such as abd pain, abd tenderness, vomiting, diarrhea and fever and the doc determined he had Gastroenteritis do I code the gastroenteritis only or do I use it as my principle dx and still code all the symptoms that follow? I have heard that, since all those symptoms are integral to the dx-gastroenteritis you don't code the symptoms but what about fever? that can be a symptom and sometimes it's not, so should I code that one too? Also, if I do code the symptoms is this a fraud?? Can I loose my certificate or raise a red flag for an audit on my practice?
Thank You