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Wiki observation/ER

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alices

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Hi all
when coding for observations(admitting Dr. is not the ER Dr.) do you also code the dx's from the ER Dr? We have a debate going on and we really need some help on this..thank you, alice
 
I say yes. Especially traumas. The admitting Dr. may not ever mention abrasions and contusions if he's observing the pt for a concussion or a spinal fx. The smaller injury diags that the ER Dr noted may be needed to cover medical neccesity for x-rays and such. Also, I find the ER documentation is more precise for applying E-codes.
 
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