ED Coding and Reimbursement Alert

Its a common diagnosis coding dilemma in EDs across the country: A patient comes in complaining of severe chest pain. It might be a heart attack, or it might be a bad case of indigestion. To the patient, the symptoms can be the same. To determine the final diagnosis, the physician must perform an extensive physical exam and order an array of tests to determine whether the patient has a cardiac-related illness. The extensive workup reveals only severe heartburnreported clinically as gastritis (i.e., 535.00, acute gastritis without mention of hemorrhage).

But, should this diagnosis be the only one reported? Should the CPT Codes for the extensive tests and procedures performed in the emergency department be linked to a diagnosis code that many payers will consider non-emergent?

Many coders have been trained to report the most specific diagnosis availablewhich means that if a diagnosis is established (i.e., gastritis), then it should be the primary code reported. They feel that only in situations where a diagnosis is not known to the physician could a sign or symptom be reported (e.g., chest pain, other -
discomfort, pain, tightness in the chest 786.59 ). Others contend that when diagnostic tests or evaluations are performed, the final diagnosis was unavailable to the physician, so only codes for signs and symptoms properly indicate the reason for the test or exam.

This is a very confusing issue for many ED coders, both for those that code for the facility and for the physician group, says Sharon Timms, RN, MSN, manager of compliance and quality management for LYNX Medical Systems, Inc., an emergency medicine coding, billing and software development company based in Bellevue, WA.

The American Hospital Associations (AHA) outpatient [diagnosis coding] guideline 12.1A specifically states for accurate reporting of ICD-9-CM diagnosis codes, the documentation should describe the patients condition, using terminology which includes specific diagnoses as well as symptoms, problems or reasons for the encounter, she explains. However, it goes on to say that codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when an established diagnosis has not been confirmed by the physician.

To Timms, this statement means that the AHA guidelines indicate that a final diagnosis should be used in lieu of codes for signs and symptoms if the final diagnosis
is available.

However, Caral Edelberg, CPC, a member of the American College of Emergency Physicians Coding and Nomenclature Advisory Committee (CNAC) and president of Medical Management Resources, Inc., an emergency medicine coding and consulting company in Jacksonville, FL, offers a different interpretation of that guideline.
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