Wiki ER Level

[livnitlarge]

I am new to ER coding and was taught that under Complexity/Medical Decision Making: most encounters done in ER are "new problem to examiner; add'l work-up planned"; because they are almost always ordering X-rays, labs, ect......I was just informed that the "add'l w/u" is what is done OUTSIDE of the ER. Any comments would be appreciated.

TIA,
M Wood

 

[lrhoward]

Any encounter done in the ER is considered new problem w/ additional work-up. Hope this helps

 

[cknittle]

ER # of DX or TX options

Any encounter done in the ER is considered new problem w/ additional work-up. Hope this helps

Hello Ms. Howard,
I do not give every encounter in ER the additional work-up. If a patient was seen and treated, then recommended follow-up with PCP, then I would give "no additional workup planned".

 

[kak6]

When the physician says follow up with PCP in 3 days if not improving this is not additional work up. However if they say contacted PCP and appointment Mon. morning @ 9am this is additional work up planned and should be used.