Wiki ER coding help

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tmerickson

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Hi! I need help from you smart people. Pt presents to ER dept, is seen by my physician that day but is not admitted. States in the record that "we will just kind of observe". Pt is admitted the next day and is induced-has baby. So, for the initial visit, do I choose from the ER codes, initial observation codes or initial hospital care. I know, I know, I should know this, but I don't. Any and all help is appreciated!:D
 
"Kind of"

Hi,

Think we would need to know a bit more about what the physician actually documented. "Kind of observed" will get them kind of nothing in terms of coding. If Observation was
separately documented including reason for Obs, attending note, time, re-evals, course of treatment etc etc, and there was 8 hours on the same day, you might have the 99234-6 series. If not and there was decent documentation of an ED visit you might have an ED visit. But all depends on documentation.

Jim
 
Hi Jim-here is report

"Pt present to office yesterday, pregnant, with history of abdominal pain. Ultrasound showed gallstones, gaver her pain meds and sent home. Presents today in ER because pain is worse and no improving. Presents afebrile and quite a bit of right upper quad pain, stabbing and sharp and goes to her back. She is holding her belly all the time.
PE: HEENT-normocephalic, atraumatic Cardo-RRR, Lungs-Clear, Abd-soft and gravid, but sever r upper quad pain to palpation.

Consulted with general surgery, they suggested we just kind of observe but if things just do not get better than will do cholecystectomy. "

Anyway he goes on and on but she isn't admitted until the next day when they induce her to have baby. The Hospital billed this dos inpatient, but wouldn't it be ER visit??? :confused:
 
Hospital Side

I think the hospital was following the three day rule and rolled the ED visit into the hospital bill. That doesn't apply to the physician side. The best I see with the documentation provided is a 99282 ED visit. If there were more documentation and MDM, it might support a higher level. But the kind of a observation statement doesn't get you there.


Jim
 
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