Wiki computer assisted coding dilema

[cgarcia08]

Hello Coders:
Please help me find documentation to support leaving in diagnoses that are picked up by a computer assisted coding program. I currently code ED accounts for which the patient is being seen for an acute problem. I'm confused as to why i would leave in a diagnosis for hyperlipidema for a patient that comes in for a fractured ankle, or even leave in a diagnosis that is picked up that is not revelent to why the patient is in the ED today. I thought that ED coding was for what the patient is being seen for, since we are not the primary care physician, shouldn't we be coding for the pertinent reason the patient is being seen and only pick up diagnoses that are relivent to the reason the patient is here and would have bearing on the current diagnosis or procedure being performed?? please help as we DO NOT have an SOP in place at the major hospital that I currently code for. Thanks in advance for your help and guidance........

Carrie the Coder.......CPC

 

[Pam Warren]

Are you coding for the ED physician or the ED facility?

If you're coding for the physician, then you'd code only what was addressed or treated at that encounter.

If you are coding for the facility, you will likely code all conditions reported, including chronic conditions that the patient has. This is done for a number of reasons. First, for reporting purposes (for the hosptial), for quality and other initiatives. Secondly, if the patient goes on to have other services at your hospital, reporting any chronic conditions may provide medical necessity.

Hope this helps.