ED Coding and Reimbursement Alert

Question: A patient presents to the ED because a glow stick broke and splashed her in the oculus dexter (OD), the right eye. The ED physician irrigates the eye and discharges the patient. In the eye section of the documentation, the physician notes a "slight conjunctivitis." The discharge diagnosis, however, is "accident to the oculus dexter by chemical splash." Should I report conjunctivitis based on what's written in the eyes section even though it's not written as a discharge diagnosis? New Mexico Subscriber Answer: You should report the chemical conjunctivitis from the irritants within the glow stick, 372.05 (Acute atopic conjunctivitis). Many experts agree that the contents of the entire medical chart are available to the coder for the purposes of selecting proper ICD-9 codes. Although you shouldn't make clinical extrapolations from the documentation, you can employ wording from various areas to determine the diagnosis code that best describes the situation.