Wiki observation/ER

[alices]

Hi all
when coding for observations(admitting Dr. is not the ER Dr.) do you also code the dx's from the ER Dr? We have a debate going on and we really need some help on this..thank you, alice

 

[rchojnowski]

I say yes. Especially traumas. The admitting Dr. may not ever mention abrasions and contusions if he's observing the pt for a concussion or a spinal fx. The smaller injury diags that the ER Dr noted may be needed to cover medical neccesity for x-rays and such. Also, I find the ER documentation is more precise for applying E-codes.

 

[alices]

re-observation/er

thank you I truly appreciate the help..alice