JParker5
Networker
Hi
I have a patient who came back to the ED during her postop period because her rib fracture has not gotten better. Normally, I would code this as a postop but what should I do when her history (comprehensive) is all about the fracture, the physician did perform an comprehensive exam and MDM was new labs, new xray and review last ER note and then codes the diagnosis as rib fx, uti and hypokalemia? Medication was given for the UTI. Do I carve out the e/m for UTI and hypokalemia but there is no information in the history for the UTI or hypokalemia.
I have a patient who came back to the ED during her postop period because her rib fracture has not gotten better. Normally, I would code this as a postop but what should I do when her history (comprehensive) is all about the fracture, the physician did perform an comprehensive exam and MDM was new labs, new xray and review last ER note and then codes the diagnosis as rib fx, uti and hypokalemia? Medication was given for the UTI. Do I carve out the e/m for UTI and hypokalemia but there is no information in the history for the UTI or hypokalemia.