BH Assessments - ER Diagnosis Codes

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I code for BH and I receive BH assessments (completed by LSCSW) in the ER. I am having issues with the diagnosis coding.

On one hand there are the diagnoses, signs, and symptoms the patient (or outside source) reports. On another hand the LSCSW reports different (or the same) diagnoses in the EMR - note I also receive paper tickets for these encounters. Then on my paper tickets the LSCSW writes down a different (or the same) diagnoses than what is in the EMR.

These assessments are detailed and can have conflicting information from the many persons involved in the patients care. What should I do? I don't want to code these incorrectly. The conflicting information makes my head spin. What all should I be taking into account? Who should I be taking into account when assigning the diagnoses? :confused:

Any help is appreciated!
 

MJ4ever

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Hi jrwhite,

I come across the same issue...
I review the chief complaint, whole note and final diagnosis assigned by the LSCW and may go by the LSCW's diagnosis but sometimes I don't.
An example is, I have LSCWs that may code Z65.8 on all their ER encounters but the CC and body of the note may talk about the patient being suicidal and homicidal with marriage problems. In that case I delete Z65.8 and use R45.851 (suicidal), R45.850 (homicidal) and Z63.0 (marriage problems). Z65.8 to me is not specific enough. Instead, I code the symptoms in this scenario.
Social Workers have always told me in the past they are not allowed to diagnose, however, they use DSM5 to see if a patient meets a certain diagnosis.
Hope that the example kind of helped explain :)
Best of Luck,

Barbara
 
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The LSCSW aren't allowed to diagnose, but they do diagnose (at least for the ER Assessments). I guess you could say it's frustrating to see multiple diagnoses that aren't related and have nothing to do with the chief complaint. Then again you can't take the patients or their families words as truth because they can contradict themselves also. I'm finding the lines are blurred in behavioral health coding, it's more subjective than other specialties I code for.

Thank you for the answer! I also try to put all the pieces together for these assessments. I just wish it was more clear cut of what we are supposed to follow.
 
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