Coding Clinic:
Outpatient Diagnosis Coding Guidelines Haven't Kept Up with Reality of ED Practice
Published on Mon Nov 01, 1999
By Caral Edelberg, CPC
ECA Consulting Editor
President, Medical Management Resources Inc, Jacksonville, FL
A new field on the UB-92 billing form, used by hospitals to report claims, will go a long way to help emergency department (ED) coders.
Hospital coders are traditionally trained to apply the most specific diagnosis available when reporting hospital charges. However, in the ED, it may be necessary to order many tests and perform many services to determine proper treatment for a patient.
ED physician group coders have often been instructed to assign the ICD-9 code that indicates the patients signs and symptoms if these problems prompted the performance of a test or service, even if the final diagnosis would not justify these tests.
This issue has been the long-standing focus of a national controversy between hospital and physician coders. There seemed to be no relief in sight until the recent decision by the National Uniform Billing Committee (NUBC) to mandate recognition of presenting symptoms or complaints as the admitting diagnosis for unscheduled outpatient visits. The decision becomes effective in April 2000.
Emergency physicians must comply with a federal law that states that every patient who presents to an emergency department must receive a medical screening examination (MSE), which is to include any necessary diagnostic tests and services sufficient to identify or rule out the presence of an emergency medical condition. Federal law further stipulates that this MSE must be provided regardless of the patients ability to pay for that treatment.
To guarantee the financial viability of the emergency care delivery system, payers generally accede to providing payment for even minimal screening services. The patients signs, symptoms and presenting complaints prompt the physician to order certain diagnostic tests and perform a particular level of history and physical examination in order to rule out a life-threatening illness and determine an appropriate disposition for the patient.
Medicare has long recognized the importance of presenting signs and symptoms, and prohibits its Medicare managed-care organizations from denying payment retrospectively based on final diagnosis (i.e., refusing to pay for services in the ED if the final diagnosis was not deemed a true emergency). Payment must be based on the patients need for treatment as demonstrated at the time of service, not after the fact.
Diagnosis Coding Rules and Who Sets Them
The rules for coding of outpatient services are centered on the American Hospital Associations Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office) revised October 1, 1995. The AHA rules suggest that coders list first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown on the medical record to be chiefly responsible for the services provided. Additional codes that describe any [...]
