Diagnosis coding of Follow Up ER

[espforu]

We have a record which the provider indicated a fall but does not state injury.

We have the documentation from the hospital shows the injury. Can we use this for coding or ? I know we can not just use a E code


Thanks,

 

[mitchellde]

We have a record which the provider indicated a fall but does not state injury.

We have the documentation from the hospital shows the injury. Can we use this for coding or ? I know we can not just use a E code


Thanks,

If there is no indication of what the patient has other than follow up the use the V67 code for other follow up. No you cannot use the facility record for the physician coding. In addition you would not use the injury code for ICD-9 for aftercare you use the appropriate V code for follow up or aftercare.

 

[espforu]

Thank you