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pamfran

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Just wondering if someone can help me with general information about emergency room coding, especially diagnosis codes. I have the levels down pretty well, but seem to run into trouble with coding diagnosis because for instance coding injury 9 codes instead of coding hematoma or what they had. I add these too but was told I don't have to put injury codes only what they are seen for. Is it only very specific diagnosis that you put? What about if they are seen for abdominal pain and they have IBS in medical history? I thought you had to use that too if it related? Anyway, new to this and need all the help I can get.

Thank you
 
Code to the highest specificity. SO if there is an injury that resulted in a hematoma code the hematoma- not the 900 code. It would be the more appropriate code. IN the abdominal pain case the doctor would have to state the IBS is causing the pain to be able to use it. If the doctor doesn't state that then you can't use it just because it is listed in the past history since it might not be the cause of the pain this time. YOu can only code the pain. Also remember that you can't code questionable diagnosis on ER since they are still outpatients :)
 
If a patient has a hematoma caused by an injury I would use the codes in 920-924.9. If the doctor says abdominal pain that is what I would code. If there is a history of IBS I would code that also. I code for the emergency room and do not get very specific diagnoses. I think it is the nature of the department.
 
I use the injusry codes in the ER and the E codes as well, on occasion I have also coded the result of the injury, without the documentation it is hard to say what the correct codes are.
 
I agree with Debra, w/out the documentation, you can't really say what the correct codes would be. I also use the injury codes & E-codes in the ER, and if applicable the result of the injury.
 
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