ED Coding and Reimbursement Alert

Fall has fallen so cold and flu season can't be far behind. That means an upsurge in visits to the emergency department. "It happens every year," says Tracie Christian, CPC, CCS-P, director of coding for ProCode in Dallas. "ED physicians will see many patients presenting with symptoms like fever, congestion, coughs, nausea and aches and pains throughout the late fall and winter months." Although these are generally not considered emergent conditions, patients without a regular physician may rely on ED staff to treat these symptoms. In other cases, patients may not want to wait for their physician's regular office hours (e.g., over the weekend), or they may have a worrisome or sudden aggravation of symptoms.
Proper Diagnosis Coding Is Crucial  
When reporting these services, Christian says, it is important for ED coders to assign the proper diagnosis codes to ensure payment. "Because colds and flu aren't regarded as true 'emergencies,' ED physicians may experience denials if the reported diagnosis code doesn't justify the medical necessity of an emergency-room visit," she says.
 
Historically, coders debated whether it was more appropriate to report the signs and symptoms that prompted the patient's visit, or the final diagnosis as established by the ED physician. Today, it's acceptable to report the signs and symptoms as documented during the history and physical exam portions of the visit. Coding experts cite two reasons for this position:  
1. Typically, it's truly the symptoms that prompted the patient to visit the ED. "If the patient knows he has a cold or the flu, he probably won't go to the emergency room," Christian says. "Usually, he is experiencing a relatively severe symptom or is in great discomfort, and is concerned that something more serious may be contributing."  
2. Given a choice of reporting signs and symptoms as opposed to a final diagnosis, symptom codes often result in a greater percentage of claims paid. "Most HMOs and PPOs have a built-in list of ICD-9 codes outlining what conditions warrant an ED visit and colds and influenza seldom appear on that list," says Todd Thomas, CCP, CCS-P, president of  Thomas and Associates, an emergency physician coding, compliance auditing and staff training firm based in Oklahoma City. "When appropriate, it's in the best interest of the physician to report the symptoms as documented."
Code the Worst First  
When assigning diagnosis codes, Thomas says, he recommends reviewing the physician's notes and assigning those that specifically reflect the reasons for the encounter. For instance, a patient with an apparent head cold may present with fever (780.6), headache (784.0), nasal congestion (478.1, other diseases of nasal cavity and sinuses) and cough (786.2). After examination the physician diagnoses a viral upper-respiratory infection (487.1, influenza, with other respiratory manifestations).  [...]