Michele1229
Networker
Hello -
We are having a debate in my office about the nature of the presenting problem. We are having conflicting views on this and we are currently auditing ER visits. In relation to the table of risk... do you look at the presenting symptom or do you look at what was found after the provider works up the patient. For example... patient presents with chest pain. After workup (labs, xrays, mri's), the provider gives a dx code of chest wall muscle strain and patient gets meds and goes home. If you go on chest pain that would be high on table of risk because chest pain could be a lot of things - some of which are serious - but if you use the final dx of chest wall muscle strain then this is more a low complexity. Thoughts?
I tend to lean towards using what the provider finds or else wouldn't everything be undiagnosed problem because we are all undiagnosed before we are seen by the doctor.
Would love input...
Thanks!
We are having a debate in my office about the nature of the presenting problem. We are having conflicting views on this and we are currently auditing ER visits. In relation to the table of risk... do you look at the presenting symptom or do you look at what was found after the provider works up the patient. For example... patient presents with chest pain. After workup (labs, xrays, mri's), the provider gives a dx code of chest wall muscle strain and patient gets meds and goes home. If you go on chest pain that would be high on table of risk because chest pain could be a lot of things - some of which are serious - but if you use the final dx of chest wall muscle strain then this is more a low complexity. Thoughts?
I tend to lean towards using what the provider finds or else wouldn't everything be undiagnosed problem because we are all undiagnosed before we are seen by the doctor.
Would love input...
Thanks!