Wiki ED diag coding

[apollo06]

I work for a company that has asked us to code anything that the provider mentions in his documentation. For example:
Pt comes into ED for laceration to lt eyelid, it is mentioned in pfsh that patient has multiple food allergies, allergy to mold and allergy to cat dander.
Besides the lac dx code, would you add the allergy codes to the encounter?
I dont believe the allergy codes have anything to do with the eye lac and would be "padding" the encounter and not medically necessary to the encounter. If you would code them just "because the provider mentioned them" can you explain to me why and any reference.
thank you for your help

 

[jimbo1231]

Diagnosis Coding

It sounds like you might be working for one of those ED specialty companies. They tend to take an aggressive approach to both CPT and ICD coding. Sometimes it makes sense for example coding symptoms even if there is a final Dx since the symptoms essentially are what drove the encounter. Sometimes like in your case they make less sense. I'm guessing you are pretty much trained to always add an ED Level to a Lac Repair code. They might be looking for DXs that would support the 99282 or 3 that you probably added to the 12011. If the physician had some concens about allergies affecting the eye and procedure and backed it up in the physicial exam it makes some sense to code for those histories. If not, it doesn't appear that there is medical necessity to code for allergies.

 

[southwick.stephanie@yahoo.com]

Good Topic fellow ED coders.

I too, have wanted to know the best way to code an ED visit/encounter, how many codes to use, and is there such thing as too many codes or over-coding?

When I first started coding for ED I was told that the right way to code ED is to "tell the story" What exactly does that mean? My trainer said to code the reason they are there and past and present medical history, as well as V-codes for long-term use of anticoagulants, anti-platelets etc.., any past surgeries such as "acquired absence of an organ. As well as code anything you can find in the ROS that may be the reason why a lab test or ct was done etc., ...then, code the impression or final diagnosis.

This to me is very time consuming, like getting caught up in the minutia. Most of it is not relevant to the visit or what brought the patient into the ED.

So if I were coding the eyelid laceration case, if the allergies had nothing to do with the injury or its healing process, I would not code it?

Is there a guideline somewhere that states the appropriate steps in the diagnosis coding an ED visit/encounter