I just started coding ERs on the facility side. I am second guessing myself and wanted to see what you would code in each of these scenarios. They are basic but I am still unsure. Basically the coding rules state to not code the symptoms which I was not coding them even if the MD listed them at the end of his note as final dx. but then was told otherwise that I should be coding all the diagnoses the MD puts down at the end. This does not seem right to me.
1. Pt comes in with nausea and vomiting. MD final dx is vomiting. Is it okay to still code N&V as final dx 787.01 since the pt has nausea in the HPI and ROS?
2. Pt comes in with N&V and diarrhea. Final dxs by MD are N&V, diarrhea and gastroenteritis.
I was just coding the gastroenteritis b/c N&V and diarrhea are symptoms of gastroenteritis but was told to code what MD documented.
3. Pt has fever and earache. Final dx is otitis media and fever. I was just coding the otitis media since fever is a symptom. Is this correct?
4. Pt comes in with low back pain. Final dx acute back pain and muscle spasm. What would you code? All 3? And would you code it to low back pain if the MD does not mention low at end of note (even though written in the note in HPI, ROS and sometimes exam.
5. Comes in with Upper back pain and final dx back strain? Do I code to upper (thoracic sprain) or code regular back sprain?
Thanks for your help!
1. Pt comes in with nausea and vomiting. MD final dx is vomiting. Is it okay to still code N&V as final dx 787.01 since the pt has nausea in the HPI and ROS?
2. Pt comes in with N&V and diarrhea. Final dxs by MD are N&V, diarrhea and gastroenteritis.
I was just coding the gastroenteritis b/c N&V and diarrhea are symptoms of gastroenteritis but was told to code what MD documented.
3. Pt has fever and earache. Final dx is otitis media and fever. I was just coding the otitis media since fever is a symptom. Is this correct?
4. Pt comes in with low back pain. Final dx acute back pain and muscle spasm. What would you code? All 3? And would you code it to low back pain if the MD does not mention low at end of note (even though written in the note in HPI, ROS and sometimes exam.
5. Comes in with Upper back pain and final dx back strain? Do I code to upper (thoracic sprain) or code regular back sprain?
Thanks for your help!