Wiki Coding from Cheif Complaint

[Jacoder]

I'm doing ER coding for our facility. The DR documented under the cheif complaint that a pt had a hip and lower back injury. The final DX is Lumbar Strain. Since he ordered an x-ray of the hip, this DX isn't going to be enough. Can I code from the cheif complaint as long as the DR wrote it or do I have to ask him/her to add it to the final DX list?

Thanks!

Jennifer

 

[Mindy Davis]

Yes you can. The chief complaint is what brought them in and the final diagnosis was determine after the x-ray was done. So I would use theirchief complaint as their first code.

Mindy

 

[AuntJoyce]

Hi Jennifer,

Remember that it is symptoms that bring the patient in and in order to arrive at a diagnosis (especially when the chief complaint is musculoskeletal in nature), x-rays are needed to both rule out and rule in firm diagnoses.

To answer your question, it is perfectly acceptable to use the presenting symptom to justify an x-ray. Had they not done the x-ray, they would never have known if there might be an underlying fracture, lytic or blastic lesions, etc.

If I were coding your scenario, it would look like this: 9928_ with the diagnoses of: 847.2 and 719.45

Hope this makes a little bit of sense.

Have a great evening,

Joyce

 

[Jacoder]

Thanks so much! I just wanted to make sure I wasn't doing anything that's against the guidelines. This will make coding and medical necessity so much easier!