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Ambulance Coding - ache and headache?

roshied

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My company was called for an emergency run for a resident who was pushed at a SNF who c/o pain in right ear and headache. Most of our patients have medicare which dont require a diagnoses code for an emergency run. I have documented E987.9 as the patient said she was pushed and fell down. Do I document a diagnosis code for the ear ache and headache?
 

cmcgarry

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Sioux Falls South Dakota
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"E" codes should not be used as a primary diagnosis, but as a supplement to show the external causes of injuries, etc. As an ambulance provider, you usually won't have a final diagnosis, but you can code the symptoms that led to the ambulance being called. I would code the headache, ear pain, and then the fall. However, E987.9 is for a fall from an unspecified high place. If the patient was pushed and fell and was not in a chair, wheelchair or bed, use E886.9; if from chair, etc, to floor, use a code from E884; if unknown for sure, use E888.9. Then use E849.7 for the place of occurrence, a residential institution (the nursing home).

Hope this helps!
 
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