Wiki ER coding question

[lmechols]

I was told by my supervisor that I should not code symptoms in chief complaint nor by vital signs, but only diagnoses from physician when coding an ER chart. Is this correct?

 

[thomas7331]

I generally agree with your supervisor. Codes should be assigned based on physician (or NPP) documentation only. The chief complaint is often recorded by hospital staff members and I would not use this for coding unless it's clear that the physician has reviewed and agrees with this is his or her assessment. Not sure what you mean by coding from vital signs, but similarly, there's no diagnostic information in vital signs that can be used for coding until the physician interprets them.

 

[OpenClaims]

That's correct that if there are definitive diagnoses, then you won't code signs/symptoms. Vital signs wouldn't be coded unless the provider is assessing them for a diagnosis and treatment plan.

 

[lmechols]

Thanks. The patient had significantly elevated blood pressure of 210/106, but physician didn't give a diagnosis of hypertension. The patient has history of hypertension and I was going to use I10, but supervisor stated, "we don't code from vitals or chief complaint, only physician diagnoses". The patient did receive Clonidine for BP.