I'm wondering how other facilies are handling these situations. When a patient presents with an elbow injury due to a fall, the physical exam is specific to the elbow, and elbow xray is done, but then the clinicain has a final impression/diagnosis of 924.9, contusion of unspecified sites. Are we suppose to use his final dx or do you code it as elbow contusion 923.11? Our clinicians are just not specific in their final diagnosis on the EMR. So frustrating! Anybody else have this issue?
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Wiki final diagnosis coding
- Thread starter kjohnson
- Start date
mitchellde
True Blue
You should code based on the documentation not based on the code selected by the clinician.
