Sabrina.
New
I've been coding ICD and E/M for a CAH for 9 years. I have started, this month, to receive accounts where the pt is admitted from ED to observation then the pt has a new or worsening condition so they are being moved back to the ED.
While this is confusing enough, I'm being given the following (for example):
Acct 1 - pt in ED 12/5 - 12/6 with ED note stating pt admit to observation on 12/5 and a progress note stating pt being transferred to higher level of care on 12/6.
Acct 2 - observation with 12/5 H&P and a progress note on 12/6 showing pt worsening so they sent back to ED. No d/c summary.
So, I can provide Dx codes for the hospital to bill but I cannot provide E/M levels because they have gone back and forth on where the pt is located and how the documentation is presented and charted.
There would not be an E/M for ED because pt admitted and seen by same provider (group) for same Dx on same DOS. I cannot provide an admit E/M without a discharge associated with it. And lastly, I cannot find any guidelines or changes that reflect moving a pt from a higher level (observation) to an acute care setting (ED) is now appropriate when the pt has additional conditions or exacerbation of original condition present.
I would very much appreciate some insight and resources to help me here.
While this is confusing enough, I'm being given the following (for example):
Acct 1 - pt in ED 12/5 - 12/6 with ED note stating pt admit to observation on 12/5 and a progress note stating pt being transferred to higher level of care on 12/6.
Acct 2 - observation with 12/5 H&P and a progress note on 12/6 showing pt worsening so they sent back to ED. No d/c summary.
So, I can provide Dx codes for the hospital to bill but I cannot provide E/M levels because they have gone back and forth on where the pt is located and how the documentation is presented and charted.
There would not be an E/M for ED because pt admitted and seen by same provider (group) for same Dx on same DOS. I cannot provide an admit E/M without a discharge associated with it. And lastly, I cannot find any guidelines or changes that reflect moving a pt from a higher level (observation) to an acute care setting (ED) is now appropriate when the pt has additional conditions or exacerbation of original condition present.
I would very much appreciate some insight and resources to help me here.